PSYCHE 


A  Concise  and  Easily  Comprehensible  Treatise 

on  the  Elements  of  Psychiatry 

and  Psychology 


for  Students  of  Medicine  and  Law 


BY 

DR.  MAX  TALMEY 


'  • '  •  }  •  » 


NEW  YORK.   1910 

The  Medico -Legal  Publishing  Company 


Copyrighted,   1910, 

BY 

F.    E.    &    E.    L.    TALMEY, 

NEW     YORK. 


aiOLOQt 
LIBRARY 


PREFACE 


No  -branch  of  medical  science  surpasses  psychiatry 
in  importance.  For  mental  disease  is  increasing  in  fre- 
quency; it  renders  its  victims  dangerous  to  the  com- 
munity; it  cuts  short  the  lives  of  some  patients  and 
permanently  disables  many;  and,  lastly,  owing  to  its 
hereditary  tendencies,  it  contributes  largely  to  race  de- 
generation. Yet  the  study  of  psychiatry  has  been  greatly 
neglected,  chiefly  due  to  the  preposterous  views,  based 
upon  superstition,  which  prevailed  in  former  times.  Until 
recently  instruction  in  psychiatry  was  seldom  given  in 
medical  schools.  To-day  lectures  in  diseases  of  the  mind 
are  held  in  the  best  medical  colleges,  but  no  final  examina- 
tion in  psychiatry  is  required  from  the  matriculates.  It 
follows,  therefore,  quite  naturally  that  they  pay  little 
attention  to  the  subject.  As  a  consequence  the  average 
general  practitioner  is  barely  acquainted  with  the  rudi- 
ments of  psychiatry. 

The  family  physician  should  be  able  to  observe  the 
earliest  and  salient  symptoms  of  a  case  of  insanity,  know 
their  import  and  immediate  dangers,  and  be  in  a  position 
to  give  a  fairly  thorough  history  to  the  consulting  alienist. 
But  psychiatrists  will  tell  you  that  such  a  family  physician 
is  rarely  met  with,  and  that  they  are  considerably  handi- 
capped by  this  lack  of  information.  This  ignorance  was 
the  writer's  incentive  in  compiling  the  present  treatise. 
He  has  endeavored  to  present  the  complicated  subject  of 

281508 


iv  PREFACE 

psychiatry  in  a  manner  sufficiently  plain  to  be  compre- 
hended with  ease  by  those  who  need  enlightenment  in 
such  matters,  but  find  it  too  laborious  to  wade  through 
more  extensive  text  books.  The  writer  hopes  that  he  has 
elucidated  the  intricate  subject  simply  and  concisely,  and 
has  brought  it  within  the  horizon  of  the  general  reader, 
and  this  will  be  his  vindication.  He  further  hopes  that 
with  the  foundation  obtained  the  general  practitioner  of 
medicine  will  be  able  to  observe  properly  and  diagnose  a 
case  of  insanity,  to  determine  the  prognosis,  and  to  treat 
the  patient  until  the  time  when  he  has  to  be  given  into 
the  care  of  the  more  experienced  specialist.  Likewise 
the  book  will  be  of  value  to  the  legal  profession  which 
frequently  has  to  deal  with  cases  complicated  by  psychi- 
atrical problems.  The  perusal  of  this  simple  treatise  will 
impart  to  an  attorney  an  adequate  knowledge  of  mental 
disease  and  thus  enable  him  to  handle  many  a  medico- 
legal subject  advantageously. 

The  Author. 
New  York,  July,  1910. 


CONTENTS 


PAGE 


Introductory  Remark I 

PART  I. 

Psychology  or  Physiology  of  the  Mental  Functions. 

Chapter    i.     Irritability  of  the  Brain 5 

Chapter    2.     Sensations  and  Sense  Impressions....  6 

Chapter    3.     Association  and  Memory 8 

Chapter   4.     Perception  11 

Chapter    5.     Feelings,  Emotions,  Moods 13 

Chapter   6.     Physiologic-anatomic       Explanation       of 

Feelings,  Emotions,  Moods 14 

Chapter    7.     Influence  of  the  Affective  State  on  the 

Psychical  Processes 18 

Chapter    8.     Physiological    Explanation   of   the   In- 
fluence of  the  Affective  State  on  the 

Ideational   Process 19 

Chapter   9.     Activity  of  the  Understanding 20 

Chapter  10.     Activity  of  the  Will 22 

Chapter  11.     Natural  Impulses,  Instincts 26 

Chapter  12.     Consciousness    2.^ 

PART  II. 
General   Pathology  of  the   Mental   Functions. 

Section  I. 
Pathology  of  Feeling  or  of  the  Affective  Sphere. 

Chapter  13.     Morbid  Depression 31 

Chapter  14.     Influence  of  Morbid  Depression  on  the 

Psychical   Functions 33 

Chapter  15.     Morbid  Exaltation 34 

Chapter  16.     Influence  of  Morbid  Exaltation  on  the 

Psychical   Functions 35 

Chapter  17.     Barrenness    of    the    Affective    Sphere  ; 

Want  of  All  Psychical  Functions. ...     36 

Chapter  18.     Irritable  Affective  State 38 

Chapter  19.     Perverse  Feelings 38 

Section  II. 
Pathology  of  Ideation. 
Chapter  20.     Morbid   Retardation   and   Acceleration 

of  the  Ideational  Process 41 

Chapter  21.     Hallucinations  42 

Chapter  22.     Auditory  Hallucinations 46 

Chapter  23.     Visual  Hallucinations 49 

Chapter  24.     Tactile,  Olfactory,  and  Gustatory  Hal- 
lucinations        50 


vi  CONTENTS 

PAGE 

Chapter  25.  Sequelae  and  Symptoms  of  Hallucina- 
tions     51 

Chapter  26.     Delusions    53 

Chapter  2y.     Classification,    Diagnostic    Value,    and 

Sequelae  of.  Delusions 55 

Chapter  28.     Differentiation  of  the  Delusions 57 

Chapter  29.     Systematized  Delusions 58 

Chapter  30.     Fixed  Delusions 59 

Chapter  31.     Disturbance  of  Memory  in  General.  ...  60 
Chapter  32.     Abnormally     Increased     Capacity     of 

Memory 61 

Chapter  33.     Diminished  Capacity  of  Memory 64 

Chapter  34.     Some  Peculiar  Disturbances  of  Memory  67 

Chapter  35.     Compulsory   Ideas 68 

Chapter  36.     Morbid   Alteration   of   the   Activity   of 

the  Understanding 73 

Section  III. 
Pathology  of  the  Activity  of  the  Will. 

Chapter  37.  Increase  and  Decrease  of  the  Frequency 

of  Volitional  Manifestations yy 

Chapter  38.  Tics,   Stereoptypy 79 

Chapter  39.  Interference,  Derailment  of  the  Will.  .  81 

Chapter  40.  Hypersuggestibility,  Negativism 82 

Chapter  41.  Morbid  Alteration  of  the  Energy 83 

Chapter  42.  Compulsory  Actions 86 

Chapter  43.  Morbid   Impulses 88 

Section  IV. 
Pathology  of  Consciousness. 

Chapter  44.     Disturbance     of     Sleep,     Somnambulism, 

Hypnotism    90 

Chapter  45.  Double  Consciousness,  States  of  Cloud- 
ed Consciousness  in  Epilepsy  and 
Hysteria   92 

Chapter  46.  Disturbance  of  Consciousness  in  Gen- 
eral Paresis  and  in  Deliria 93 

Chapter  47.     Disturbance  of  Self-consciousness 94 

Section  V. 
Somatic  Disturbances  in  the  Insane. 

Chapter  48.     Disturbance  of  Sleep  and  of  the  General 

Nutrition,   Sitophobia 95 

Chapter  49.     Motor  Disturbances 97 

Chapter  50.     Disturbance  of  Sensibility 98 


CONTENTS  vii 

PAGE 

Chapter  51.     Disturbance    of    the    Activity    of    the 

Heart   \ 99 

PART  III. 
Etiology  of  Insanity. 

Chapter  52.     Classification  of  the  Causes  of  Insanity.   103 

Chapter  53.     Influence  of  CiviHzation 104 

Chapter  54.     Influence  of  Religion 106 

Chapter  55.     Heredity   107 

Chapter  56.     Stigmata  of  Hereditary  Predisposition 

to  Insanity no 

Chapter  57.     Psychical   Influences 113 

Chapter  58.     Influence  of  the  Infectious  Diseases..    115 

Chapter  59.     Influence  of  Poisons 116 

Chapter  60.     Influence  of  Trauma 118 

PART  IV. 
Course  (Prognosis)  and  Therapy  of  the  Psychoses. 

Section  I. 
Course  (Prognosis)  of  the  Psychosis. 

Chapter  61.     Onset  of  the  Psychoses 123 

Chapter  62.     Duration  of  the  Psychoses 125 

Chapter  63.     Termination  of  the  Psychoses 128 

Sect  [OX  IT. 
Therapy  oi-   [\<.\m'i-y. 
Chapter  64.     Common    Reluctance    to    Institutional 
Treatment  of  the  Insane.     Responsi- 
bility of  the  Family  Physician 132 

Chapter  65.     Transporting    Insane    Patients    to    the 

Asylum  134 

Chapter  66.     Insane  Asylum 137 

Chapter  67.     Treatment  of  the  Individual  Symptoms 

of  Insanity. 141 

Chapter  68.     Hypnotism    in    the    Treatment    of    In- 
sanity     147 

PART  V. 
Special   Pathology  of   Insanity. 

Chapter.  69.     Classification  of  the  Psychoses 151 

Chapter  70.     Psychoses  and  Age  of  Patient 153 

Section  I. 
Mental  Diseases  Commencing  After  the  Early  Stages 

OF  THE  General  Development  of  the  Organism. 
Chapter  71.     Melancholia    154 


Vlll 


CONTENTS 


Chapter  ^2.     Stupor 159 

Chapter  73.     Mania  162 

Chapter  74.     Hallucinatory  Insanity 170 

Chapter  75.     Primary  Insanity,  Paranoia 176 

Chapter  76.     Secondary  Insanity 181 

Chapter  yj.     Delirium   185 

Chapter  y^.     Secondary  Feeble-mindedness,  Second- 
ary Dementia 189 

Chapter  79.     Primary    Feeble-mindedness,    Primary 

Curable  Dementia 192 

Section  II. 

Mental  Diseases   Dating   From    Earliest   Childhood, 
Idiocy,  Cretinism. 

Chapter  80.     Definition,  Classifications,  and  Physical 

Stigmata  of  Idiocy 195 

Chapter  81.     Inferior   Idiots 197 

Chapter  82.     Superior  Idiots,  Imbeciles 199 

Chapter  83.     Moral  Idiocy,  Moral  Insanity 204 

Chapter  84.     Querulous    Insanity,    Morbid  Litigious- 

ness   209 

Chapter  85.     Originary   Insanity    211 

Chapter  86.     Contrary  Sexual   Feeling,  Sexual   Per- 
versity      212 

Chapter  87.     Cretinism  214 

Section  III. 
Diatheses  of  Insanity. 

Chapter  88.     Hereditary  Predisposition  to  Insanity, 

Hereditary  Insanity 218 

Chapter  89.     Hysterical  Insanity 219 

Chapter  90.     Phrenasthenia,   Psychasthenia 222 

Chapter  91.     Dementia  Praecox 224 

Chapter  92.     Recurrent    Insanity,    Manic-depressive 

Insanity   233 

Chapter  93.     Epileptic  Insanity 242 

Chapter  94.     Paretic  Insanity 246 

Chapter  95.     Alcoholic  Insanity 257 

Chapter  96.     Delirium   Acutum 263 

Chapter  97.     Traumatic  Insanity 265 

Chapter  98.     Insanity  in  Organic  Brain  Diseases.  .  .  .  267 

Chapter  99.     Senile  Insanity 269 

Index   273 


INTRODUCTORY  REMARK 


The  definition  of  psyche  or  mind  as  the  capacity  of 
Hving  organisms  for  certain  manifestations,  such  as  per- 
ceiving, feeHng,  remembering,  thinking,  wilHng,  etc.,  is 
not  exhaustive,  but  sufficient  for  the  purpose  of  convey- 
ing to  the  student  a  clear  conception  of  the  elements  of 
psychology  and  psychiatry.  Anything  relating  to  the 
psyche  or  mind  is  designated  with  the  attribute  psychical 
or  mental.  The  bodily  organ  which  forms  the  basis  of 
the  mind  is  the  brain.  All  the  processes  of  the  body, 
the  vegetative  as  well  as  the  psychical  functions,  depend 
on  the  brain.  The  treatment  of  the  vegetative  functions 
appertains  to  neurology  and  neuropathology.  Psychiatry 
deals  with  the  morbid  changes  of  the  psychical  functions 
of  the  brain,  while  the  normal  psychical  phenomena  form 
the  subject  of  psychology.  A  clear  knowledge  of  the 
former  cannot  be  obtained  without  a  preceding  study  of 
the  latter.  The  following  concise  description  of  the  ele- 
ments of  psychology  will  facilitate  the  proper  under- 
standing of  the  subsequent  exposition  of  the  elements 
of  psychiatry. 


PART  I.    . 

PSYCHOLOGY  OR  PHYSIOLOGY 
OF  THE  MENTAL  FUNCTIONS 


Chapter  I. 
IRRITABILITY  OF  THE  BRAIN. 

The  brain  cortex  possesses  the  quaHty  of  irritability, 
i.  e.,  the  tendency  and  capabiHty  of  reacting  to  external 
stimuli.  The  irritability  may  be  lowered  to  a  minimum, 
and  yet  no  morbid  change  may  be  present.  As  a  rule 
the  irritablity  varies.  In  the  course  of  the  day  it  first 
increases,  then  it  decreases  and  recedes  sometimes  to  a 
very  low  level,  due  to  the  exertions  during  the  day. 
Restitution  to  the  normal  takes  place  during  sleep. 

Far  greater  than  by  work  is  the  influence  exerted 
on  the  cerebral  irritability  by  the  blood  circulation.  If 
both  carotid  arteries  are  compressed  (p.  67),  the  cerebral 
metabolism  becomes  greatly  diminished,  although  the 
brain  still  receives  blood  through  the  vertebral  arteries. 
The  result  of  this  reduction  of  the  blood  supply  is  that 
the  individual  becomes  quickly  unconscious,  i.  e.,  he  is 
unaware  of  what  is  going  on  around  him ;  after  awaking 
he  has  no  knowledge  of  what  has  transpired.  Such 
diminution  of  the  irritability  can  be  produced  only  arti- 
ficially, but  does  not  occur  under  ordinary  circumstances. 

How  does  it  occur  that  the  irritability  is  periodic, 
decreasing  in  the  day  to  be  restored  during  sleep?  The 
brain  behaves  like  a  muscle  which  becomes  fatigued 
through  work.  During  work  the  metabolism  is  increased 
and  waste  products  are  generated  in  great  excesses.  These 
metabolic  products,  therefore,  cannot  be  carried  off  not- 
withstanding the  enhanced  circulation  during  work.  The 
accumulation  of  the  products  of  fatigue  lowers  the  irri- 


6  '  *'"   •  PSYCHE 

tability  of  the  brain.  Hence  in  the  course  of  the  day 
we  become  less  and  less  susceptible  to  external  stimuli. 
During  normal,  healthy  sleep  the  brain  accomplishes  very 
little  work,  the  generation  of  new  products  of  metabolism 
is  greatly  diminished,  and  those  accumulated  before  can 
be  carried  off.  The  processes  of  repair  being  in  excess, 
the  irritability  reappears. 

Sleep  is,  therefore,  not  a  special  function,  as  was 
formerly  assumed,  but  merely  a  certain  state  of  the 
brain.  This  can  also  be  proved  from  psychical  pathology. 
Many  a  patient,  after  having  gone  through  a  psychosis, 
lacks  the  ability  for  certain  mental  functions,  the  psycho- 
pathological  process  having  destroyed  the  cerebral  mech- 
anisms by  which  these  functions  are  exercised.  Perma- 
nent insomnia,  however,  is  never  met  with  in  a  patient 
after  the  cessation  of  the  acute  psychopathic  manifesta- 
tions. Now,  if  sleep  were  a  function  of  the  brain,  the 
cerebral  mechanism  for  exercising  this  function  would, 
in  some  cases  of  mental  disease,  be  destroyed  and  perma- 
nent sleeplessness  result. 


Chapter  11. 
SENSATIONS  AND  SENSE  IMPRESSIONS. 

The  paths  by  which  the  brain,  although  excluded 
from  the  external  world  by  the  solid  cranial  capsule,  is 
accessible  to  external  influences  are  the  blood  and  lymph 
circulation,  the  senses,  and  the  muscles  via  the  nerves. 

Effects  of  the  circulation  on  the  brain  are  observed 
after  hypodermic  injections  and  after  medication  through 
the  alimentary  and  respiratory  tracts.  When  morphine 
is  administered   subcutaneously,   cerebral   symptoms   are 


PSYCHOLOGY  7 

soon  noticed;  the  morphine  is  conveyed  by  the  blood  to 
the  brain  and  exerts  its  influence  on  it.  AlcohoHc  drinks 
cause  hilarity;  alcohol  enters  the  blood  and  is  carried  to 
the  brain.  A  protracted  stay  in  a  room  filled  with  car- 
bondioxide  gas  produces  a  state  of  stupefaction. 

The  most  perfect  way  by  which  external  influences 
reach  the  brain  are  the  senses,  sight,  hearing,  touch,  taste, 
and  smell.  The  eye  reacts  to  light,  i.  e.,  to  vibrations  of 
the  ether.  These  produce  a  change  in  the  retina,  on 
which  "a  picture  is  formed.  The  change  in  the  retina  is 
conducted  to  the  brain  through  the  optic  nerve.  When 
we  "see,"  this  means  merely  that  our  brain  cortex,  i.  e., 
the  cortex  of  the  occipital  lobe,  has  been  altered  in  a  cer- 
tain manner  by  ether  vibrations  emanating  from  a  lumin- 
ous object.  A  certain  number  of  vibrations  of  the  air 
per  second  change  the  organ  of  Corti.  The  change  is 
conveyed  through  the  acoustic  nerve  to  the  cortex  of  the 
temporal  lobe.  When  this  part  of  the  brain  undergoes 
the  consequent  alteration,  we  say,  we  "hear"  or  we  have 
a  sensation  of  hearing.  The  same  is  the  case  with  the 
senses  of  touch,  taste,  and  smell,  and  the  numerous  sen- 
sations effected  through  the  skin,  for  instance,  by  heat, 
cold,  etc.  The  sensations  leave  in  the  brain  certain  perma- 
nent changes  called  sense  impressions  or  sensory  images. 
There  are  accordingly  visual,  acoustic,  tactile,  gustatory, 
and  olfactory  sense  impressions  or  sensory  images. 

Finally,  the  brain  is  influenced  by  the  muscles.  The 
new-born  child  cannot  grasp  an  object,  it  cannot  make 
voluntary  muscular  movements.  The  movements  of  its 
muscles  are  at  first  purely  automatic.  But  just  as  the 
stimulation  of  a  sense  organ  produces  a  sensation,  so 
also  does  any  muscular  movement  give  rise  to  a  motor 
sensation.      Such   sensations   leave   in  the  brain  certain 


8  PSYCHE 

permanent  changes,  called  motor  impressions  or  motor 
images.  Through  the  frequent  reflex  movements  motor 
impressions  are  stored  up  in  the  brain.  Only  after  the 
accumulation  of  sufficient  motor  images  the  child  learns 
to  grasp  objects  voluntarily. 

The  nature  of  the  cerebral  elements  in  which  the 
impressions  are  stored  up  is  not  known.  Because  of 
their  number  the  medullated  nerve  fibres  are  more  read- 
ily adapted  to  receive  the  irritations  of  the  brain  during 
a  whole  lifetime  than  the  cells.  W.  His  calls  the  cerebral 
fibres  which  supposedly  receive  the  stimulations  of  the 
hrdiin ''sensation  fibres"  {''Empfindungsfasern").  F.  H. 
V.  Grashey  agrees  with  His.  Others  do  not  assume  sen- 
sory fibres,  but  only  "sensation  cells"  {"Empfindungs- 
zellen").  But  no  matter  which  of  these  elements  receive 
the  stimuli,  a  sensation  ensues  when  they  are  excited.  A 
permanent  change  remains  in  the  sensory  element.  It  is 
called  impression,  and  may  be  regarded  as  the  result  of 
the  work  done  by  the  process  of  stimulation.  (Chapter 
8,  p.  19.) 


Chapter  HI. 
ASSOCIATION  AND  MEMORY. 

The  various  sensations  are  localized  in  definite  areas 
of  the  brain ;  for  instance,  the  cortex  of  the  occipital  lobe 
serves  for  the  visual  sensations.  These  areas,  however, 
are  neither  isolated  nor  disconnected. 

The  sensory  elements,  fibres  or  cells,  of  any  one 
sense  are  connected  with  each  other.  The  connecting 
fibres  are  called  association  fibres  (Fig.  i,  a).  In  this 
way  sensations  may  be  associated. 


PSYCHOLOGY  9 

By  another  set  of  association  fibres  the  sensory  ele- 
ments of  one  sense  communicate  with  those  of  the  other 
senses  (Fig.  2,  aj.  A  visual  sensation  may  thus  be 
effected  through  auditory  stimuli.  When  we  hear  the 
name  of  an  object  known  to  us,  we  have  its  image  be- 
fore us. 


a 


on 


on 


on 


Fig.   I. 

The  sensory  elements,  s,  of  a  sense  are  connected  by  asso- 
ciation fibres,  a.  Visual  sensations  received  from  the  retina, 
R,  by  way  of  the  optic  nerve,  on,  may  be  associated  by  means 
of  the  association  fibres,  a. 


A  sensation  not  obtained  directly  from  the  peri- 
phery, i.  e.,  the  senses,  the  muscles,  or  some  other  organ, 
but  by  way  of  association  fibres  in  the  brain,  is  called  a 
memory  image  or  an  idea.  Memory  depends  on  asso- 
ciation, as  a  simple  example  will  explain.  A  dog  seeing  a 
whip  for  the  first  time,  pays  no  attention  to  it.  If  a  blow 
be  dealt  the  dog  with  the  whip,  he  receives  a  sensation 


lO 


PSYCHE 


of  pain  which  is  associated  with  the  image  of  the  whip, 
and  he  runs  away.  Thereafter  when  the  dog  merely  sees 
the  whip,  he  runs  away  just  as  he  did  when  he  first 
received  the  blow. 

Three  factors  are  requisite  for  the  accomplishment 


on 


V 


on 


on 


an 


\ 


an 


an 


Fig.  2. 


When  the  auditory  organ,  E,  is  stimulated,  a  visual  sensa- 
tion may  be  effected.  The  irritation  travels  from  the  ear,  E, 
through  the  acoustic  nerve,  an,  to  the  auditory  center,  as, 
thence  through  association  fibres,  ai,  to  the  visual  center,  vs. 


of  an  idea.     Firstly,  sensations  must  have  taken  place; 
secondly,  the  sensations  must  be  associated  with  one  an- 
other; thirdly,  impressions  of  the  sensations  must  have 
been  retained  in  the  brain.     Only  then  ideas  can  arise. 
Bearing  in  mind  the  foregoing  explanation  of  sen- 


PSYCHOLOGY  ii 

sations,  impressions,  association,  and  ideas — memory  im- 
ages— we  may  define  memory  in  the  following  way. 
Memory  is  the  capability  of  producing,  or  bringing  into 
consciousness,  ideas  by  zvay  of  association.  Patholog- 
ically ideas  may  be  awakened  in  another  way,  namely 
by  hallucinations — which  will  be  explained  later  (p.  44). 
Such  ideas  are  called  hallucinatory  ideas.  They  are  not 
brought  about  by  way  of  association.  Hence  they  do 
not  belong  to  the  true  province  of  memory. 


Chapter  IV. 
PERCEPTION. 

When  the  irritation  brought  about  at  the  periphery 
by  an  external  stimulus  arrives  in  the  brain  cortex  and 
produces  a  change  in  a .  cerebral  element,  a  sensation 
takes  place.  Normally  the  individual,  somehow  or  other, 
becomes  aware  of  the  change,  and  we  say,  he  "sees,"  he 
"hears,"  etc.  But  it  is  conceivable  that  he  may  fail  to 
become  aware  of  the  change.  This  is  physiologically 
the  case  with  the  sensations  of  the  earliest  days  of  life, 
and  occurs  only  pathologically,  as  a  rule,  in  the  adult. 
A  person  is  mentally  blind — ''seelenblind" — or  psychi- 
cally deaf — "seelentaub" — if  he  does  not  become  aware 
of  the  result  of  visual  or  auditory  stimulation.  Hence 
we  may  distinguish  a  sensation  which  one  is  aware  of, 
and  a  sensation  which  one  is  not  aware  of.  The  latter 
is  a  pure  sensation,  the  former  a  pure  perception.  Both 
are  seldom  realized  in  adult  life. 

In  contradistinction  to  pure  perception  ordinary  per- 
ception of  an  object  is  a  complicated  process  in  which 
association     and     reproduction — memory — are     instru- 


12  PSYCHE 

mental.  The  different  points  of  the  object  furnish  sep- 
arate images.  These  are  stored  up  in  different  cerebral 
elements  which  are  connected  by  association  fibres. 
When  one  partial  image  is  presented  to  a  sense,  all  the 
other  partial  images  are  called  forth — reproduction — by- 
way of  association,  and  the  individual  perceives  the  com- 
posite image  of  the  whole  object.  In  all  likelihood  a 
composite  image  is  not  deposited  in  one  cerebral  element. 
When  the  child  learns  to  see  an  object,  it  does  not  receive 
its  whole  image  at  once,  but  by  separate  perceptions  it 
learns  to  compose  the  image  of  the  object.  The  single 
perceptions  are  stored  up  in  different  cerebral  elements 
as  sense  impressions  which  unite  to  form  the  complex 
image  of  the  object  whenever  a  partial  image  is  awak- 
ened. 

Three  modes  of  perceiving  may  be  distinguished. 
I )  Simple  perception  consists  chiefly  of  actual,  momen- 
tary sensations.  2)  Intuition  contains  actual  sensations 
and  memory  images.  3)  Phantasy  is  composed  mainly 
of  memory  images.  A  fourth  mode  of  perceiving  will 
be  treated  later  (Chapter  21,  p.  42). 

Most  of  the  perceptions  of  the  adult  are  intuitions. 
A  very  young  child  receives  only  simple  perceptions.  As 
experience  grows,  actual  sensations  are  combined  with 
memory  images.  When  a  person  enters  his  unilluminated 
room  at  night,  he  is  fairly  well  aware  of  everything 
around  him.  The  few  actual  sensations,  which  he  receives 
even  in  darkness,  are  supplied  by  supervening  memory 
images,  and  both  impart  to  him  a  correct  apprehension 
of  his  surroundings.  The  pupil  who  has  just  learned  to 
read,  needs  a  comparatively  long  time  to  grasp  a  long 
word,  while  one  who  is  already  experienced  in  reading 
sees  the  whole  word  at  once,  immediately  after  noticing 


PSYCHOLOGY  13 

the  first  syllable,  memory  images  furnishing  useful  aid 
at  the  moment  of  the  actual  visual  sensation  which  the 
first  syllable  produces. 

During  the  process  of  phantasy  we  abandon  our- 
selves entirely  to  our  thoughts  after  having  withdrawn 
our  senses  from  external  influences.  The  memory  im- 
ages are  combined,  one  image  awakens  another,  often 
against  our  will.  This  play,  this  coming  and  going  of 
the  memory  images,  is  called  the  ideational  process,  the 
course  of  ideas,  or  the  train  of  ideas. 


Chapter  V. 
FEELINGS,  EMOTIONS,  MOODS. 

Simultaneously  with  every  sensation  arises  a  certain 
feeling.  When  a  flash  of  light  strikes  the  eye,  the  visual 
sensation  obtained  is  agreeable  or  disagreeable;  a  certain 
sound  has  an  exciting  or  soothing  effect.  The  feelings 
accompanying  the  sensations  are  called  sense  feelings  or 
affective  tones  of  the  sensations.  They  are  best  observed 
in  children.  The  sight  of  some  object,  the  hearing  of 
some  sound,  produces  in  the  child  an  agreeable  or  dis- 
agreeable feeling,  and  the  child  manifests  its  pleasure  or 
displeasure  in  some  obvious  manner. 

Not  only  the  sensations,  but  also  all  other  psychical 
processes  are  accompanied  by  feelings.  Every  idea, 
every  volitional  act,  every  operation  of  the  understanding, 
gives  rise  to  certain  feelings  which  may  be  called  the 
affective  tones  of  these  psychical  processes. 

A  feeling  is  not  a  lasting  psychical  state,  but  a 
transitory,  comparatively  slow  process,  and  its  effect  on 
the  other  psychical  processes   does  not  exceed  medium 


14  PSYCHE 

intensity.  When  however  a  continuous  series  of  feelings 
is  distinct  from  preceding  and  following  psychical  proc- 
esses, thus  representing  a  separate  entity,  and  at  the  same 
time  produces  effects  of  greater  intensity  than  a  single 
feeling  does,  such  a  sum  of  feelings  is  called  an  emotion. 
(Wilhelm  Wundt.) 

Several  simple  feelings,  arising  simultaneously  or 
shortly  one  after  the  other,  produce  a  composite  feeling 
of  the  first  order.  Composite  feelings  of  a  higher  order 
result  from  composite  feelings  of  the  first  order.  The 
composite  feelings  differ  from  the  emotions  chiefly  by 
the  greater  effects  which  the  latter  exert  on  the  other 
psychical  processes. 

Composite  feelings  often  pass  into  protracted  states. 
Such  states  are  called  moods  or  affective  states.  The 
moods  form  the  transition  between  feelings  and  emo- 
tions. 

There  is  an  infinite  variety  of  feelings  and  emo- 
tions. The  most  conspicuous  emotions  are  those  of  an 
agreeable  or  disagreeable  nature,  such  as  joy,  pleasure, 
hope,  surprise,  sorrow,  displeasure,  disappointment,  an- 
xiety, fear,  fright,  anger,  rage,  etc. 

The  child  manifests  few  affective  tones.  In  the 
adult,  however,  the  scale  of  affective  tones  and  emotions, 
from  the  highest  delight  to  the  greatest  fright,  is  almost 
infinite. 


Chapter  VI. 


PHYSIOLOGIC=ANATOMIC    EXPLANATION    OF 
FEELINGS,  EMOTIONS,  MOODS. 

The  arising  of  affective  tones  may  be  explained  by  the  follow- 
ing hypothesis.     The  sensory  centers  are  connected  with  a  certain 


Fig.  3. 

When  the  eye,  R,  or  the  ear,  E,  is  stimulated,  the  irritation  travels 
through  the  optic  nerve,  on,  or  the  acoustic  nerve,  an,  to  the  visual 
center,  vs,  or  to  the  acoustic  center,  as,  and  a  visual,  or  auditory 
sensation  takes  place.  The  irritation  travels  further  through  asso- 
ciation fibres,  a-j,  to  the  vasomotor  center,  vc,  thence  through  vaso- 
motor nerves,  vn,  to  the  cerebral  blood  vessels,  cbl,  the  affection  of 
which  changes  the  nutritive  state  of  the  brain,  thus  producing  an 
affectiv?  tone. 


i6  PSYCHE 

other  center  by  means  of  association  fibres  (Fig.  3,  ao).  The  stimu- 
lation of  this  center  arouses  an  affective  tone  just  as  the  stimulation 
of  a  sensory  center  gives  rise  to  a  sensation.  When  a  stimulus 
reaches  an  organ  (Fig.  3,  R.  K),  the  irritation  travels  through  an 
afferent  nerve  (on,  an),  to  the  sensory  center  (vs,  as),  thence 
through  an  association  fibre  (as)  to  the  center  of  the  affective  tones 
(vc).  The  irritation  of  the  former  results  in  a  sensation,  and  of 
the  latter,  in  an  affective  tone.  It  thus  follows  that  every  sensation 
will  be  accompanied  by  an  affective  tone. 

The  center  of  the  affective  tones  is  identical  with  the  vaso- 
motor center.  When  this  center  is  irritated,  the  blood  vessels 
contract,  the  resistance  in  the  circulation  is  increased,  less  blood 
flows  through  the  brain,  and  its  state  of  nutrition  is  altered.  The 
stimulation  of  any  center  affects  also  that  of  the  circulation  by  way 
of  association  fibres  (Fig.  3,  ^2)  and  produces  a  sudden  change  in 
the  nutritive  state  of  the  brain.  This  change  gives  rise  to  a  certain 
feeling,  an  affective  tone. 

A  simple  experiment  shows  that  the  vasomotor  center  partici- 
pates in  the  production  of  feelings  and  their  combinations,  moods 
and  emotions.     When  a  rabbit  is  frightened,  its  ear  becomes  pale. 

The  condition  of  the  brain  depends  upon  its  nutri- 
tion, so  that  it  varies  when  the  nutrition  is  inadequate, 
sufficient,  or  excellent.  Insufficient  nutrition  produces  a 
state  of  anxiety,  and  in  fright  the  brain's  nutrition  is 
lowered  to  a  minimum.  Pleasurable  feelings  correspond 
to  a  good  nutritive  state  of  the  brain. 

The  brain  being  enveloped  by  the  unyielding  solid  cranial 
capsule,  some  mechanism  must  exist  for  its  adaptation  to  sudden 
changes  in  circulation.  The  space  occupied  by  the  receding  blood 
must  be  filled  out  by  some  other  material.  The  hypothesis  has  been 
advanced  that  liquor  cerebro-spinalis  vicariously  replaces  the  blood. 
When  more  blood  flows  to  the  brain,  the  space  for  it  is  supposedly 
created  by  cerebro-spinal  fluid  receding  into  the  vertebral  canal.  This 
is  physically  not  impossible,  but  would  not  suffice  to  provide  enough 
room  for  the  inflowing  arterial  blood.  Besides,  the  walls  of  the 
vertebral  canal  also  offer  great  resistance  to  the  afflux  of  the  cere- 
bro-spinal fluid.  Another  regulation,  therefore,  must  exist  to  render 
the  instantaneous  change  of  the  cerebral  blood  quantity  possible. 
This  regulation  is  furnished  by  the  venous  system,  i.  e.,  the  venous 
sinuses  and  the  veins  emptying  into  them.     The  pressure   in  the 


PSYCHOLOGY  17 

cerebral  veins  is  slight.  With  each  pulse  beat  which  drives  more 
arterial  blood  into  the  brain,  venous  blood  is  simultaneously  pushed 
out  of  the  veins  into  the  sinuses  and  thence  into  the  jugular  veins. 
In  this  way  room  is  created  for  the  arterial  blood.  Conversely 
venous  blood  occupies  the  room  when  the  affix  of  arterial  blood  is 
diminished.  It  is  even  conceivable  that  with  sufficient  reduction 
of  the  pressure  in  the  arteries  a  reflux  into  the  brain  of  venous 
blood  could  take  place. 

The  arterial  blood  supply  is  of  vital  importance  to  the  brain 
as  shown  by  the  experiment  consisting  in  the  compression  of  the 
carotid  arteries  (p.  5).  Death  through  hanging  is  caused  by  anaemia 
of  the  brain,  and  follows  suddenly  or  at  least  very  quickly.  Any 
reduction  of  the  blood  supply  lowers  the  faculties  of  the  brain. 

An  affective  tone  arises  through  a  sudden  change 
in  the  nutrition  of  the  brain,  the  vasomotor  center  being 
secondarily  affected  at  any  psychical  process.  An  affec- 
tive state  or  mood  thus  depends  on  the  nutritive  state  of 
the  brain.  When  the  brain  is  in  a  state  of  good  nutri- 
tion, a  feeling  of  well-being,  pleasure,  joy,  is  present. 
When  the  brain's  nutrition  is  impaired,  a  cerebral  dys- 
pnoea, so  to  say,  ensues,  causing  displeasure,  pain,  depres- 
sion, anxiety,  fear,  etc. 

Feelings,  moods,  and  emotions  admit,  therefore,  of  a 
physiologic-anatomic  explanation.  Anatomically  they  have 
their  basis  in  the  vasomotor  center  and  in  the  association 
fibres  by  which  it  is  connected  with  the  other  cerebral 
centers.  Physiologically  the  feelings  and  their  combina- 
tions are  founded  upon  the  transmission  of  every  stimu- 
lation from  the  senses  and  other  organs  to  the  vasomotor 
center  through  the  tracts  described,  and  upon  the  influ- 
ence which  this  center  then  exerts  on  the  circulatory 
system. 

Different  affective  states  are  equivalent  to  different 
states  of  cerebral  nutrition.  In  the  sane  individual  the 
affective  state  undergoes  a  change  by  the  arising  of  a 


i8  PSYCHE 

new  affective  tone.  He  falls  into  a  state  of  anxiety  by 
experiencing  a  sensation  through  which  the  nutrition  of 
the  brain  is  impaired.  In  the  individual  of  unsound  mind, 
however,  the  feelings  and  their  combinations  vary  also 
in  another  manner. 

To  explain  the  great  variety  of  affective  states,  we 
must  assume  that  the  nutritive  states  of  the  brain  are 
very  manifold. 

Two  affective  tones,  occurring  simultaneously  or 
shortly  one  after  the  other,  may  neutralize  one  another. 
One  misses  a  valuable  thing.  He  looks  for  it  everywhere 
in  vain  and  begins  to  worry.  But  the  worry  disappears 
at  once  when  further  searching  brings  forth  the  lost 
valuable.  We  laugh  at  a  joke,  but  when  we  are  in  a  state 
of  depression,  the  inclination  to  laugh  is  suppressed. 


Chapter  VH. 

INFLUENCE  OF  THE  AFFECTIVE  STATE  ON  THE 
PSYCHICAL  PROCESSES. 

The  affective  state  exerts  a  great  influence  on  the 
psychical  processes.  In  a  cheerful  mood  our  judgment 
is  entirely  different  from  that  formed  in  a  mood  of  de- 
pression. A  merchant  about  to  go  into  bankruptcy  meets 
a  friend.  The  latter  passes  by  without  greeting  him. 
The  merchant  at  once  thinks  that  his  friend  despises 
him.  It  does  not  occur  to  him  that  his  friend  may  not 
have  seen  him.  If,  however,  the  same  merchant  were 
in  a  joyous  frame  of  mind,  and  a  friend  passing  on  the 
street  paid  no  attention  to  him,  he  would  say  to  himself, 
my  friend  is  so  distracted,  so  absorbed  in  his  own 
thoughts  that  he  does  not  even  notice  his  best  friends 
who  cross  his  way.     In  a  cheerful  mental  state  we  have 


PSYCHOLOGY  19 

the  inclination  to  see  everything  in  a  favorable  light; 
everything  appears  gloomy  to  us  when  we  are  depressed. 

A  person  suddenly  frightened  may  for  the  moment 
be  unable  to  speak.  Speech  becomes  often  inhibited  by 
sudden  depression.  Memory  and  the  ideational  process 
are  impeded  by  the  disturbed  state  of  cerebral  nutrition. 
On  the  other  hand,  the  stream  of  our  thoughts  flows 
easily  when  we  are  in  an  exalted  frame  of  mind. 

To  no  less  a  degree  than  the  ideation,  the  volitional 
activity  may  be  influenced  by  changes  in  the  cerebral 
nutrition  or  in  the  affective  state. 


Chapter  VIII. 

PHYSIOLOGICAL  EXPLANATION  OF  THE  IN- 

FLUENCE  OF  THE  AFFECTIVE  STATE  ON 

THE  IDEATIONAL  PROCESS. 

The  following  hypothesis  will  explain  the  inter- 
relation between  mood  and  ideational  process.  The 
transmission  of  impulses  through  the  nervous  elements 
is  facilitated  or  impeded  according  to  the  tension  and 
resistance  prevailing  in  them.  The  higher  the  tension, 
the  more  easily  the  resistance  is  overcome.  The  reduc- 
tion of  the  cerebral  nutrition  in  a  state  of  depression 
(Ch.  6,  pp.  14-15)  causes  a  lowering  of  the  tension.  The 
resistance  is,  therefore,  surmounted  only  with  great  diffi- 
culty. The  sense  impressions,  i.  e.,  the  permanent  changes 
in  the  sensory  elements  (pp.  6-8)  brought  about  by  the 
processes  of  stimulation,  may  be  assumed  to  be  changes 
of  resistance  in  these  elements.  Violent,  i.  e.,  disagree- 
able, stimulations  cause  a  great  change  and  considerable 
lowering  of  resistance.  Mild,  i.  e.,  agreeable,  stimuli,  on 
the  other  hand,  produce  little  change  and  slight  diminu- 


20  PSYCHE 

tion  of  resistance.  Hence  the  resistance  remaining  in 
cerebral  elements  which  have  undergone  a  disagreeable 
excitement  is  small,  but  in  those  having  experienced 
an  agreeable  stimulation  is  still  great.  The  ideational 
process  depends  upon  stimulation  of  cerebral  elements 
by  way  of  association  (pp.  8-11,  13),  and  not  directly 
by  actual  sensations.  Such  stimulation,  however,  is  weak 
and  suffices  to  affect  only  elements  with  slight  resistance, 
i.  e.,  those  which  have  been  disagreeably  influenced  at  a 
former  occasion.  But  it  cannot  excite  elements  with 
great  resistance,  or  those  to  which  pleasurable  impres- 
sions have  once  been  imparted.  It  follows  that  in  a  state 
of  depression  or  impaired  cerebral  nutrition  with  dimin- 
ished nervous  tension  the  memory  images  will  be  of  an 
unpleasant  character.  For  the  weak  stimulation  by  way 
of  association  can  be  effective  only  in  cerebral  elements 
of  little  resistance,  which  contain  impressions  of  un- 
pleasant experiences.  When  the  affective  state  becomes 
exalted,  the  nutrition  is  improved  and  the  tension  is 
raised.  Stimulation  by  way  of  association  is  then  suffi- 
cient to  affect  elements  with  great  resistance,  which  harbor 
pleasant  impressions.  The  enhancement  of  the  nervous 
tension  helps  to  surmount  great  resistances.  The  memory 
images  are,  therefore,  of  a  cheerful  nature,  for  they  arise 
in  elements  in  which  impressions  of  pleasant  sensations 
are  stored  up. 

Chapter  IX. 

ACTIVITY  OF  THE  UNDERSTANDING. 

The  ability  of  the  brain  to  perceive  an  object  is  not 
always  the  same.  At  some  moments  it  is  better  fitted 
for  certain  perceptions  than  at  others.     The  condition 


PSYCHOLOGY  21 

of  the  brain  in  which  an  object  is  perceived  in  the  most 
favorable  manner,  and  which  is  associated  with  a  pecu- 
Har  affective  tone,  is  called  attention.  Perception  aug- 
mented by  the  advantageous  influence  of  attention  is 
called  apperception. 

Apperception  forms  that  basis  of  the  activities  of 
imagination  and  understanding.  The  materials  for  these 
activities  are  sensations,  simple  ideas,  and  collective  ideas. 
In  both  activities  sensations  and  memory  images  are  com- 
bined in  various  ways,  and  thus  higher,  more  complicated 
perceptions  are  acquired.  Collective  ideas  are  dissolved 
into  their  component  elements  or  into  simpler  psychical 
products.  The  activity  of  the  understanding  differs  from 
the  activity  of  the  imagination  in  that  the  former  searches 
and  establishes  comparisons  and  relations  between  the 
psychical  elements  and  products.  Comparisons  and  re- 
lations play  an  important  part  in  the  activity  of  the  un- 
derstanding, but  are  neglected  in  the  activity  of  the 
imagination. 

The  process  of  associating  ideas  in  a  regular  way 
with  a  certain  end  in  view  is  called  reasoning.  The  result 
or  conclusion  hereby  arrived  at  is  a  judgment. 

That  form  of  the  activity  of  the  understanding 
which  constructs,  by  combination,  complicated  psychical 
products  out  of  sensations  and  memory  images  is  called 
synthesis  or  induction.  Dissolving  psychical  compounds 
into  their  components  is  called  analysis  or  deduction. 

Reason  is  the  capability  of  forming  abstract  concep- 
tions, of  operating  with  them  and  conforming  one's  ac- 
tions accordingly.  The  difference  between  reason  and 
understanding,  considered  in  a  medical  aspect,  is  only 
quantitative.  Kant  probably  started  from  a  medical  point 
of  view  when  in  his  definition  of  reason  he  said:     *'A11 


22  PSYCHE 

our   knowledge    commences    with    our    senses,    proceeds 
thence  to  understanding,  and  ends  in  reason." 


Chapter  X. 
ACTIVITY  OF  THE  WILL. 

When  a  stimukis  is  appHed  directly  to  a  muscle,  the 
latter  contracts  and  a  movement  ensues.  Such  a  move- 
ment is  a  direct  movement.  If  however  a  muscle  con- 
tracts, when  some  other  organ,  for  instance  the  skin,  is 
irritated,  such  muscular  contraction  is  called  a  reflex 
movement. 

The  process  of  a  reflex  movement  is  best  illustrated  by  a 
simple  diagram.  If  a  portion  of  the  skin  (Fig.  4,  ps)  be  irritated, 
the  impulse  is  conveyed  through  the  sensory  nerve  (sn)  to  the 
posterior  horn  of  the  spinal  cord  (ph).  Thence  it  travels  through 
an  association  fibre,  which  forms  a  part  of  the  reflex  arc  (ra),  to 
the  anterior  horn  (ah)  and  then  through  the  motor  nerve  (mn) 
to  the  muscle  (M)  and  causes  the  same  to  contract  with  a  con- 
sequent movement  of  the  part.     This   is   a  pure   reflex  movement. 

Reflex  movements  are  independent  of  the  will,  tak- 
ing place  even  when  the  brain  has  been  severed  from  the 
body.  When  the  skin  of  a  frog  just  decapitated  is 
pricked,  the  muscles  of  the  irritated  part  contract.  The 
movements  of  the  new-born  child  are  also  reflex  move- 
ments. The  child  sucks  reflexly,  moved  to  this  action  by 
some  remote  irritation.  The  movements  of  the  child's 
extremities  are  reflex  movements. 

When  an  end-organ  is  stimulated,  the  impulse,  after  its 
entrance  into  the  spinal  cord,  takes  also  another  course  besides  the 
one  described  in  the  foregoing  illustration.  From  the  posterior 
horn  (Fig.  5,  ph)  it  travels  through  the  sensory  tracts  (st)  to  the 
center  of  sensibility  in  the  brain    (sc)    and  leaves  in  the  cerebral 


PSYCHOLOGY 


23 


cortex  a  permanent  change,  a 
sense  impression  (Ch.  2,  p.  7). 
Likewise  when  a  muscle  con- 
tracts, an  impulse  is  trans- 
mitted from  the  muscle  (M) 
through  an  afferent  fibre  of  the 
motor  nerve  (mni)  to  the 
anterior  horn  (ah),  thence 
through  the  motor  tract  (mti) 
to  the  motor  center  in  the 
brain,  and  leaves  in  the  cortex 
a  permanent  alteration,  a  motor 
impression  or  motor  image  (p. 
8).  Frequent  stimulation  ren- 
ders conduction  along  the 
motor  paths  more  easy  by  re- 
ducing their  resistances,  and. 
establishes  motor  images.  These 
two  conditions  given,  a  slight 
irritation,  e.  g.,  a  visual  per- 
ception is  sufficient  to  effect  a 
movement.  The  visual  impulse 
is  transmitted  from  the  retina 
(R)  through  the  optic  nerve 
(on)  to  the  visual  center  (vs), 
thence  through  an  association 
fibre  (ai)  to  the  motor  center 
(mc).  Here  the  movement  is 
initiated,  the  impulse  traveling 
further  through  the  motor  tract 
(mt),  anterior  horn  (ah),  and 
the  motor  nerve  (mn)  to  the 
muscle  (M)  which  contracts. 

The  following  example 
will  more  clearly  illus- 
trate the  process.  When 
a  child's  arm  is  pricked 
with  a  knife,  the  arm  is 
withdrawn,  the  irritation 
being   transmitted   to   the 


Fig.  4. 

The  explanation  is  directly  con- 
tained in  the  text. 


24 


PSYCHE 


Fig.  5- 
The  contraction  of  a  muscle,  M, 
causes  an  irritation  to  be  transmitted 
from  the  muscle  through  an  afferent 
fibre  of  the  motor  nerve,  mui,  to  the 
anterior  horn,  ah,  thence  through  the 
motor  tract,  mti,  to  the  motor  center, 
mc,  where  a  motor  impression  is 
produced.  Hereafter  a  visual  sensa- 
tion may  cause  a  movement.  The 
visual  impulse  travels  from  the  re- 
tina, R,  through  the  optic  nerve,  on, 
to  the  visal  center,  vs,  thence  through 
an  association  fibre,  ai,  to  the  motor 
center,  mc,  and  further  through  the 
motor  tract,  mt,  anterior  horn,  ah, 
motor  nerve,  mn,  to  the  muscle,  M, 
which  contracts. 

muscles  of  the  arm  along  the 
reflex  arc  described  (Fig.  5). 
The  withdrawing  of  the  arm  is 
not  a  voluntary  movement,  it 
ensues  also  when  the  child  is 
asleep.  The  irritation  through 
the  pricking  is  conveyed  also  to 
the  center  of  sensibility  (sc) 
and  leaves  here  an  impression 
of  pain.  If  the  child  has  seen 
the  knife,  a  sense  impression, 
the  image  of  the  knife,  is  simul- 
taneously established  in  the 
visual  center  (vs).  Thereafter 
when  the  child  merely  sees  the 
knife  approaching  its  arm,  it 
pulls  the  arm  away.  It  per- 
forms a  voluntary  movement, 
it  acts  intelligently,   while  the 

withdrawing  of  the  arm  when  it  was  first  pricked  with 

the  knife,  was  merely  a  reflex  movement. 


Fig.  5 


PSYCHOLOGY  25 

Every  movement  originating  in  the  brain,  like  the 
one  just  described,  is  a  volitional  movement.  Volitional 
movements  constitute  the  will.  They  take  place,  as  ex- 
plained above,  only  after  sufficient  motor  images  have 
been  stored  up  in  the  motor  center  through  frequent 
reflex  movements,  and  the  resistances  in  the  motor  tracts 
have  been  diminished. 

Sometimes  will  is  expressed  not  by  executing,  but 
by  suppressing  movements,  although  the  incitement  to 
perform  them  is  present,  for  instance,  by  suppressing  a 
painful  outcry  while  suffering  pain. 

From  the  preceding  explanations  results  the  follow- 
ing definition  of  will.  Will  is  the  capability  of  re  enforc- 
ing motor  images  so  that  movements  take  place,  and  also 
of  weakening  motor  images  so  that  movements  are  sup- 
pressed. 

According  to  the  foregoing  interpretation  of  voli- 
tional movements  or  will,  all  actions  of  man  and  animals 
would  take  place  in  an  entirely  regular  manner  following 
definite  fixed  causes  physically  preestablished.  Freedom 
of  the  will  would  be  inconsistent  with  this  interpretation. 
Some  philosophers,  however,  maintain  that  will  is  free. 
They  either  give  another  explanation  of  will,  or  attempt^ 
somehow  or  other,  to  bring  their  view  into  conformity 
with  the  above  interpretation — indeterminism.  But  even 
the  adherents  of  this  doctrine  must  admit  that  there  is 
an  indisputable  delimitation  of  freedom  of  the  will.  The 
latter  is  particularly  lacking  in  many  morbid  mental  con- 
ditions. When  a  movement  can  be  demonstrated  to 
originate  from  morbid  factors,  it  is  an  action  executed 
in  a  state  of  want  of  freedom  of  the  will.  From  a  med- 
ical point  of  view  freedom  of  the  will  is  excluded  in  all 
actions  which  are  founded  on  a  psychopathological  basis. 


26  PSYCHE 

Chapter  XL 
NATURAL  IMPULSES,  INSTINCTS. 

Psychical  phenomena,  also  worthy  of  our  attention, 
which  pertain  to  the  activity  of  the  will,  are  the  natural 
impulses  or  instincts. 

According  to  Wundt  a  simple  volitional  action,  i.  e., 
such  an  action  that  has  only  a  single  motive,  is  an  ''im- 
pulse action."  Such  actions,  originating  from,  or  having 
their  motive  in,  certain  sensations  and  sense  feelings,  are 
termed  instincts.  The  alimentive  and  generative  organs 
mainly  give  rise  to  those  sensations  and  feelings  which 
call  forth  instincts.  The  individual  ''impulse  actions" 
arise  from  stimuli,  external  or  internal. 

To  explain  the  complex  character  of  many  instinc- 
tive actions,  generically  acquired  qualities  of  the  nervous 
system  must  be  assumed  in  consequence  of  which  con- 
genital reflex  mechanisms  are  set  in  motion  and,  without 
previous  training,  carry  out  complicated  actions  when- 
ever stimuli  act  upon  specific  organs. 

Instances  of  instincts  in  animals  are  the  impulses 
of  many  animals  to  build  houses  and  nests,  as  with 
beavers,  birds,  ants;  or  else  to  live  in  matrimony,  mon- 
ogamic  or  polygamic,  as  with  many  birds;  or  else  to 
form  social  communities,  as  with  bees,  ants,  termites. 

The  view  that  instincts  are  peculiar  to  animals  and 
lacking  in  man  is  erroneous.  On  the  contrary,  instincts 
are  very  numerous  in  man.  Especially  the  alimentive 
and  generative  instincts  are  innate  in  man  as  well  as  in 
animals.  The  human  instincts  are  most  easily  recog- 
nized in  infancy  and  childhood.  Sucking  is  a  well  de- 
veloped instinct  of  the  new-born.  By  instinct  the  infant 
cries  at  discomfort,  pain,  or  solitude,  and  smiles  at  be- 


PSYCHOLOGY  27 

ing  caressed.  Imitation  is  a  typical  instinct,  the  imita- 
tive actions  being  entirely  unpremeditated  and  ensuing 
whenever  certain  perceptions  take  place.  The  earliest 
period  of  life  excepted,  this  instinct  is  common  to  all 
ages  of  man.  The  young  child  imitates  gestures  and 
sounds.  At  a  later  age  it  repeats  the  games  of  others. 
The  imitativeness  of  adults  is  seen  in  the  tendency  to 
speak  and  behave  like  others,  to  yawn  or  laugh  when 
others  do  so,  and  so  on.  Another  human  instinct  is  the 
repugnance  towards  certain  substances,  such  as  blood, 
pus,  dejecta.  A  strong  human  instinct  is  the  impulse  to 
propagate  the  species,  which  finds  its  expression  in  the 
various  manifestations  of  love;  and  the  strongest  in- 
stinct is  the  impulse  of  self-preservation,  which  causes 
man  to  prefer  the  most  miserable  life  to  death. 


Chapter  XII. 

CONSCIOUSNESS. 

In  every-day  language  the  term  consciousness  desig- 
nates various  mental  states  which  have  only  little  rela- 
tion to  one  another.  There  is  a  difference,  for  instance, 
between  saying,  we  are  in  a  state  of  consciousness,  and 
we  have  self -consciousness.  The  definition  of  con- 
sciousness, therefore,  is  very  difficult.  Some  maintain 
that  it  is  impossible  to  define  consciousness.  But  even 
though  a  definition  of  the  term  cannot  be  exhaustive,  yet 
for  our  purposes  the  following  explanation  will  suffice. 
Consciousness  is  that  mental  state  in  zvhich  we  are  en- 
abled to  receive  sensations,  to  gather  perceptions,  to 
operate  zcith  them,  and  to  act  at  zvill.  An  unconscious 
person  is  unable  to  experience  sensations,  to  acquire  per- 


28  PSYCHE 

ceptions,  and  to  act  intelligently;  he  does  not  see,  nor 
hear,  nor  execute  voluntary  movements.  Self-conscious- 
ness, on  the  other  hand,  is  the  capability  of  separating 
one's  own  individuality  from  the  external  world,  of  rec- 
ognizing it  as  something  distinct,  something  special.  An 
individual  receives  cognizance  not  only  of  external  things, 
but  also  of  his  own  body,  for  instance  of  the  attitude  of 
his  limbs,  i.  e.,  he  has  self -consciousness. 

Self -consciousness  includes  orientation,  which  de- 
pends on  memory  and  constitutes  the  knowledge  of  our 
relation  to  our  environment  and  our  comprehension  of 
time  and  space. 


PART  II. 

GENERAL  PATHOLOGY  OF  THE 
MENTAL  FUNCTIONS 


SECTION  I. 

PATHOLOGY    OF    FEELING    OR    OF    THE 
AFFECTIVE    SPHERE 


Chapter  XIII. 
MORBID  DEPRESSION. 

Morbid  depression  is  a  very  frequent  pathological 
alteration  of  the  mood.  It  has  great  similarity  with 
normal  mental  dejection,  from  which  it  is  sometimes 
hardly  distinguishable ;  at  most  it  differs  from  it  through 
its  intensity.  Unmistakable  criteria,  therefore,  are  re- 
(juired  to  confirm  the  morbidity  of  a  depressed  state  of 
mood.  There  are  three  such  criteria.  One  of  them 
consists  in  the  absence  of  any  external  cause  for  the 
depression.  The  experiences  of  the  patient  preceding 
liis  depression  do  not  contain  anything  on  which  it  may 
be  founded.  The  cause  of  the  depression  is  an  internal 
one,  it  lies  within  the  patient  himself.  Some  patients 
are  even  able  to  state  that  nothing  disagreeable  has  oc- 
curred to  them,  that  they  do  not  know  what  may  be  the 
cause  of  their  sadness.  If  apparently  there  be  any  cause, 
it  is  entirely  inadequate  to  explain  the  intensity  of  the 
depression.  This  disproportion  between  cause  and  effect 
is  generally  overlooked  by  the  inexperienced. 

The  second  criterion  is  the  unusually  long  duration 
of  the  depression.  Misfortunes  often  happen  in  life 
j^bout  which  one  cannot  be  consoled  in  the  beginning. 


32  PSYCHE 

But  a  sane  person,  after  a  comparatively  short  time,  be- 
comes reconciled  to  the  new  state  of  affairs,  grows 
calmer,  and  regains  his  former  mental  disposition. 
Morbid  depression,  however,  lasts  for  weeks  and  months, 
and  even  years,  and,  what  is  especially  pathognomonic, 
increases  with  time  instead  of  decreasing  as  is  the  case 
with  normal  mental  dejection. 

The  third  criterion  is  expressed  by  the  saying: 
''Sublata  causa  tollitur  effectus."  If  one  is  in  a  sad 
mood  on  account  of  pecuniary  losses,  his  sadness  disap- 
pears when  the  lost  sum  is  restored.  An  insane  patient, 
however,  who  mourns  for  having  lost  his  fortune,  will 
continue  to  do  so  even  when  millions  are  presented  to 
him,  and  his  mournfulness  will  not  abate,  but  rather  in- 
crease at  the  announcement  that  he  has  recovered  his 
lost  fortune.  It  is  impossible  to  remove  the  morbid 
depression  by  external  reasons  and  by  persuasion  and 
consolation.  Solace  and  kind  words  may  bring  about 
an  appeasement,  but  it  is  only  apparent  or  at  least  very 
brief.  Proud  of  the  success  obtained  through  his  clever 
words  of  consolation,  the  comforter  comes  to  his  patient 
on  the  following  day  and  finds  that  he  has  not  only 
achieved  no  permanent  good  result,  but  has  made  things 
even  worse,  the  patient  being  now  more  depressed  than 
ever. 

The  three  criteria  to  determine  the  morbidity  of  a 
depressed  mood  may  be  summed  up  as  follows :  Depres- 
sion of  mood  is  pathological,  if  it  is  not  explained  by  any 
cause,  or  only  an  insufficient  reason  is  advanced;  if  it  is 
not  mitigated  by  time,  but  lasts  unusually  long  and  even 
increases  with  time;  finally,  if  it  cannot  be  abolished  by 
removing  the  ostensible  cause,  by  external  reasons,  by 
words  of  consolation. 


GENERAL  PATHOLOGY  33 

This  mood  or  affective  state  is  called  the  melan- 
cholic affective  state  and  is  characteristic  of  melancholia. 

Morbid  depression  increases  now  and  then  to  an 
emotional  attack  of  anxiety  and  fear.  The  patient,  until 
now  apathetic,  insensible,  and  indifferent,  becomes  greatly 
agitated,  runs  about  hither  and  thither,  wailing  loudly 
about  his  fancied  misfortune.  These  attacks  are  tran- 
sitory, and  the  patient  lapses  into  the  former  depression. 


Chapter  XIV. 

INFLUENCE    OF    MORBID    DEPRESSION    ON    THE 
PSYCHICAL  FUNCTIONS. 

The  symptoms  of  mental  disease  are  in  constant 
interrelation.  A  change  in  one  psychical  province  modi- 
fies the  others.  In  this  interrelation  we  have  a  ready 
means  to  detect  malingerers  and  an  important  factor  for- 
ensically.  It  is,  therefore,  advisable  always  to  consider 
the  various  symptoms  of  mental  disease  in  their  mutual 
relations. 

The  psychical  functions  undergo  a  considerable 
modification  through  morbid  depression  of  the  mood. 

The  ideational  process,  the  coming  and  going  of 
the  memory  images,  is  retarded  during  pathological  de- 
pression. The  sphere  of  ideas  is  restricted,  some  ideas 
are  not  at  all  accessible  to  the  patient. 

From  the  retardation  of  the  ideational  process  re- 
sults an  impariment  of  memory.  The  patient  cannot 
recollect  many  events  at  all  or  only  with  great  difficulty. 
The  memory  images  that  can  be  reproduced  are  such  as 
have  been  brought  about  by  painful  sensations  (pp. 
19-20). 

A  patient  in  morbid  depression  is  unable  to  per- 


34  PSYCHE 

ceive  correctly.  His  perceptions  are  composed  of  gloomy, 
woeful  memory  images.  The  patient  imagines  himself 
to  be  lost  forever,  considers  his  present  circumstances 
and  his  future  in  a  most  unfavorable  light,  and  thus 
arrives  at  delusions. 

The  volitional  manifestations  of  the  patient  are 
diminished  in  frequency,  his  energy  is  reduced.  His 
movements  are  few  and  sluggish,  he  prefers  to  sit  qui- 
etly on  one  spot.  Sometimes  he  even  fails  to  carry  out 
the  movements  required  for  taking-  food  and  for  other 
physical  needs. 

When  however  the  patient  is  seized  with  an  emotion 
of  anxiety,  the  psychical  functions  assume  a  different 
form  (p.  33).  While  until  then  he  did  not  give  expres- 
sion to  any  ideas,  being  silent,  unconcerned,  apathetic, 
he  now  runs  about  quickly,  wringing  his  hands  and  wail- 
ing aloud.  He  complains  of  a  distressing  pressure  over 
the  chest — the  so-called  precordial  anxiety.  He  tries 
to  get  a  hold  of  all  kinds  of  dangerous  instruments  to 
injure  himself  and  others.  In  this  way  it  appears  as 
though  the  ideational  process  were  accelerated  and  the 
sum  of  ideas  increased.  In  reality,  however,  it  is  one 
and  the  same^  idea  which  always  returns  while  the  state 
of  agitation  lasts.  The  will  power  is  increased,  the 
patient  in  his  anxiety  exhibiting  great  energy  and  force. 


Chapter  XV. 

MORBID  EXALTATION. 

The  opposite  of  morbid  depression  of  the  mood  is 
}]iorhid  exaltation.  The  patient  maintains  he  is  in  ex- 
cellent circumstances,  hale  and  hearty,  rich  like  Croesus, 


GENERAL  PATHOLOGY  35 

and  his  future  roseate.  He  is  remarkably  cheerful  and 
inclined  to  pun  and  joke.  The  criteria  for  morbid  de- 
pression (pp.  31-32)  are  also  applicable  in  establishing 
the  morbidity  of  an  exalted  mood.  It  is  even  more  diffi- 
cult to  find  an  external  cause  which  would  explain  the 
great  cheerfulness  of  the  patient.  For  the  happy  events 
of  life  are,  indeed,  much  rarer  than  the  untoward  expc- 
periences.  The  second  criterion  of  morbid  depression 
(p.  31)  is  also  more  striking  in  morbid  exaltation.  If 
a  fortunate  event  has  put  a  sane  person  in  an  extremely 
joyful  frame  of  mind,  he  regains  his  mental  equilibrium 
after  a  comparatively  brief  time.  Morbid  exaltation, 
however,  lasts  unabated  for  weeks  and  months.  The 
third  criterion  (p.  32)  also  comes  into  consideration.  It 
is  impossible  to  drag  the  patient  down  from  his  heaven 
of  bliss.  If  one  Job's  news  after  the  other  be  conveyed 
to  him,  his  cheerfulness  cannot  be  lessened.  If  one  were 
to  tell  the  patient  that  his  future  looked  unfavorable,  he 
would  laugh  at  him  or  break  out  into  a  rage  against  the 
bearer  of  the  ill  tidings.  But  the  anger  is  forthwith 
replaced  by  the  former  cheerfulness.  This  affective  state 
is  called  the  maniacal  affective  state  and  is  characteristic 
of  mania. 


Chapter  XVI. 

INFLUENCE   OF    MORBID    EXALTATION    ON    THE 
PSYCHICAL  FUNCTIONS. 

The  ideational  sphere,  memory,  perception,  voli- 
tional activity,  undergo  a  marked  alteration  through  the 
maniacal  affective  state.  The  course  of  ideas  is  accele- 
rated, one  memory  image  seems  to  drive  the  other  away, 


36  PSYCHE 

and,  what  has  appropriately  been  termed  "flight  of  ideas," 
is  brought  about.  The  contents  of  the  ideas  are  of  a 
joyful  nature.  The  patient  easily  recollects  the  events 
of  his  life,  but  only  the  fortunate  ones  occupy  his  mind 
(pp.  19-20).  He  sees  everything  in  a  favorable  light,  his 
perceptions  have  a  friendly,  cheerful  character.  He  thus 
judges  his  circumstances  wrongly  and  overestimates  his 
powers,  i.  e.,  he  arrives  at  delusions.  These  are  just  the 
opposite  of  the  melancholic  delusions.  The  volitional 
acts  are  increased  in  frequency.  The  energy  is  enhanced 
with  respect  to  the  application  of  gross  motor  power 
(p.  83),  but  diminished  in  regard  to  persistence.  In 
overcoming  obstacles  the  patient  may  use  great  force, 
but  he  is  unable  to  carry  out  persistently  a  definite  plan 
of  action,  forgetting  quickly  what  he  has  just  intended 
to  do,  owing  to  flight  of  ideas.  Suddenly  a  new  thought 
flits  through  his  mind,  and  the  plan  determined  upon  is 
immediately  abandoned. 


Chapter  XVH. 

BARRENNESS     OF     THE     AFFECTIVE     SPHERE; 
WANT   OF   ALL   PSYCHICAL   FUNCTIONS. 

The  desolation  or  barrenness  of  the  affective  sphere 
consists  in  the  lack  of  feelings,  of  affective  tones.  It  is 
characteristic  of  idiocy.  Aside  from  the  extreme  emo- 
tions, the  highest  joy  and  the  deepest  sadness,  the  sane 
person  is  possessed  of  an  almost  unlimited  gammut  of 
affective  tones  which,  increasing  with  his  experiences, 
show  innumerable  gradations.  This  great  variety  of 
affective  tones  is  lacking  in  the  idiot.     He  is  either  con- 


GENERAL  PATHOLOGY  37 

stantly  indifferent,  or  angry,  or  joyful,  or  depressed. 
The  finer  intermediate  grades  of  feeling  are  missing.  He 
has  no  conception  of  filial  affection,  of  friendship,  of 
patriotism,  of  feeling  of  honor  or  shame,  and  so  on. 
Emotions,  however,  appear  very  readily,  and  surpass  in 
intensity  the  emotions  of  normal  individuals.  A  sane 
person  in  an  emotion  of  sadness  never  displays  such 
intense  expression  of  pain  as  the  idiot.  When  an  indi- 
vidual manifests  the  most  violent  anger  at  the  slightest 
inconvenience,  we  are  justified  in  suspecting  that  we  are 
dealing  with  an  idiot. 

The  desolation  of  the  affective  sphere  is  not  always 
congenital,  as  in  idiocy,  but  may  be  also  acquired.  The 
acquired  barrenness  of  the  province  of  feeling  is  the 
consequence  of  a  psychosis  or  represents  its  terminal 
stage.  A  person  whose  mind  would  show  the  most  deli- 
cate reactions  to  all  kinds  of  influences  may  become 
entirely  dull  after  having  passed  through  a  psychosis. 
He  takes  no  interest  in  his  friends,  the  fate  of  his  near- 
est relatives  does  not  concern  him,  and  he  is  indifferent 
to  his  own  lot.  Some  patients  are  aware  of  the  devasta- 
tion of  their  affective  sphere,  of  the  defective  reaction  of 
their  mind,  but  cannot  help  it.  They  complain  of  not 
possessing  the  same  feelings  they  used  to,  and  reveal  to 
those  around  them  that  "their  mind  and  heart  are  dead- 
ened." 

Here  may  be  mentioned  the  condition  called  stupor 
and  characterized  by  an  almost  complete  standstill  of  all 
psychical  functions.  Feelings  and  emotions  are  wanting, 
and  there  is  hardly  any  intimation  of  an  idea.  The 
patients  are  as  if  inanimate.  Their  limbs  remain  in  any 
position  given  to  them,  although  such  position  may  be 
disagreeable  or  even  painful. 


38  PSYCHE 

Chapter  XVIII. 
IRRITABLE  AFFECTIVE     STATE. 

Contrary  to  the  barrenness  of  the  affective  sphere 
is  the  irritable  affective  state.  There  are  individuals  who 
respond  too  readily  to  stimuli,  to  whom  even  the  ordinary 
sense  perceptions  cause  discomfort  and  even  pain.  A 
flash  of  light  makes  their  eyes  ache,  a  strong  sound  hurts 
their  ears. 

Another  kind  of  increased  irritability  consists  in  un- 
usual duration  and  intensity  of  the  emotions.  It  is  met 
with  in  those  tainted  by  heredity  and  in  idiots.  Such 
individuals,  at  the  slightest  cause,  may  fall  into  a  state 
of  great  affliction  lasting  exceedingly  long  and  sometimes 
ending  in  unexplainable  suicide.  Such  emotions  are  not 
interrupted  by  a  shock  as  has  been  observed  in  a  patient 
who  was  in  such  a  frame  of  mind.  He  fell  into  the 
water  and  was  pulled  out  of  it  in  an  unconscious  condi- 
tion. Notwithstanding  this  violent  shock  his  emotional 
attitude  was  unchanged  upon  regaining  consciousness. 


Chapter  XIX. 

PERVERSE  FEELINGS. 

Perversities  of  the  affective  sphere  are  not  infre- 
quent. They  are  met  with  chiefly  in  idiots  and  epileptics. 
The  patients,  in  certain  circumstances,  do  not  react  in  a 
normal  manner,  the  affective  tones  corresponding  to  these 
occasions  being  perverse  or  absent.  Some  patients  do 
not  hesitate  to  take  into  their  mouths  the  most  nauseating 
things.  This  perversity  has  been  called  coprophagia. 
The  patients  eat  their  own  faeces  and  those  of  others, 


GENERAL  PATHOLOGY  39 

drink  their  urine.  Sometimes  such  perverse  acts  are 
called  forth  by  delusions.  The  patients,  for  instance, 
imagine  that  they  lose  strength  with  their  urine,  that  by 
drinking  it  they  would  be  better  enabled  to  defend  them- 
selves against  the  plots  of  enemies.  Coprophagia  is  a 
pathognomonic  sign  of  insanity,  and  the  statement  has 
correctly  been  made  that  coprophagia  alone  suffices  to 
establish  the  diagnosis  insanity  beyond  doubt,  the  most 
cunning  malingerer  being  unable  to  swallow  his  own 
dejecta  (p.  27). 

To  a  very  slight  degree  similar  phenomena  are  en- 
countered physiologically.  Pregnant  women  manifest  the 
strangest  concupiscences.  Odors  ordinarily  shunned  offer 
them  pleasurable  sensations,  etc. 

Some  patients  lack  the  feeling  of  shame.  They  are 
not  in  the  least  ashamed  to  denude  themselves  in  the 
presence  of  others,  to  speak  of  sexual  matters  without 
the  slightest  reserve,  to  masturbate  openly,  etc.  The  ten- 
dency of  some  patients  to  indulge  in  obscene  language — 
coprolalia — or  indecent  gestures  is  due  chiefly  to  the 
want  of  the  feeling  of  shame. 

Morbid  feeling  underlies  the  compulsory  ideas 
(p.  y2).  This  is  easily  comprehensible  especially  in  the 
case  of  those  compulsory  ideas  which  appear  as  morbid 
fears — the  so-called  phobias — (pp.  70-71 ) .  Patients  labor- 
ing under  agoraphobia,  on  reaching  a  public  square  or 
street,  are  seized  with  great  fear  so  that  they  are  unable 
to  cross  it.  Some  patients  succeed  to  pass  the  street  by 
certain  devices,  as  by  grasping  firmly  somebody's  hand, 
or  by  getting  a  hold  of  a  carriage,  or  by  fixing  their  eyes 
on  a  certain  object  on  the  opposite  side  of  the  street, 
unremittingly  staring  at  the  object  for  a  while,  and  then 
suddenly  darting  towards  it. 


40  PSYCHE 

Other  examples  of  morbid  fears  are  contained  in 
the  chapter  on  compulsory  ideas  (70). 

Another  perverse  feeling  is  perverse  sexuality.  It 
is  chiefly  congenital  and  rarely  acquired.  Homosexuality 
is  its  most  frequent  and  conspicuous  type.  It  consists 
in  aversion  to  the  other  sex  and  inclination  to  one's  own 
sex.  In  men  it  leads  to  pederasty  and  produces  complete 
impotence  towards  the  female  sex. 


SECTION  IL 
PATHOLOGY    OF    IDEATION 


Chapter  XX. 

MORBID  RETARDATION  AND  ACCELERATION  OF 
THE  IDEATIONAL  PROCESS. 

The  anatomic  connection  of  the  sensory  elements  in 
the  brain  (pp.  8-10)  renders  the  association  of  ideas  or 
memory  images  possible.  When  in  one  manner  or  an- 
other a  memory  image,  stored  up  long  ago  as  an  impres- 
sion in  a  sensory  element,  is  awakened,  many  other  mem- 
ory images  are  called  forth,  one  after  the  other,  from 
cerebral  elements  which  are  associated  with  the  first  one. 
In  this  way  a  constant  play  of  ideas  is  going  on,  called 
the  ideational  process. 

The  ideational  process  may  be  morbidly  retarded, 
less  ideas  appearing  in  a  unit  of  time  than  normally.  The 
retardation  of  the  ideational  process  is  the  usual  symptom 
of  melancholia  and  is  due  to  depression  of  mood.  The 
association  is  difficult,  certain  memory  images  cannot  be 
reproduced  (pp.  19-20,  33).  With  this  delay  of  the 
course  of  ideas  is  connected  an  impairment  of  memory 
The  retardation  of  the  ideational  process  is  also  met  with 
after  psychoses.  Some  insanities  terminate  with  such  a 
devastation  of  the  ideational  sphere  that  a  great  part  of 
the  impressions  stored  up  in  the  brain  cortex  seems  to 
be  entirely  wiped  out,  and  the  patient's  wealth  of  expe- 
riences lost. 


42  PSYCHE 

The  opposite  of  retardation  is  morbid'  accelera- 
tion of  the  ideational  process.  Some  patients  pro- 
duce an  immense  number  of  ideas  in  a  unit  of  time. 
Ideas  just  intrude  upon  them.  One  idea  rapidly  follows 
the  other,  giving  rise  to  the  s^anptom  appropriately 
termed  "flight  of  ideas"  (pp.  36,  19-20).  The  ac- 
celeration of  the  ideational  process  is  the  usual  symp- 
tom of  mania.  The  memory  appears  to  be  improved, 
the  patient  disposing  of  his  stored  up  experiences  with 
great  facility.  On  the  other  hand,  he  is  unable  to  de- 
velop his  thoughts  in  the  same  way  as  a  sane  person,  for 
he  cannot  retain  an  idea  long  enough,  deviating  quickly 
from  the  train  of  his  thoughts.  All  his  perceptions  are, 
therefore,  characterized  by  superficiality. 


Chapter  XXI. 

HALLUCINATIONS. 

The  hallucinations  form  a  very  important  morbid 
alteration  in  the  ideational  sphere.  A  few  preliminary 
remarks  are  necessary  for  a  clear  definition  of  the  term. 
It  has  been  said  a  sensation  to  which  no  external  object 
corresponds,  is  a  hallucination,  for  instance,  seeing  an 
object  which  is  not  present.  Related  to  this  is  tlie  illu- 
sion which  has  been  defined  as  a  sensation  to  which  an 
external  object  corresponds,  but  not  in  the  same  form 
as  perceived  by  the  patient.  For  instance,  if  the  patient 
sees  a  person  who  actually  stands  before  him,  and  the 
person  appears  to  him  to  have  fiery  eyes  or  to  have  his 
head  surrounded  by  a  halo,  he  has  an  illusion  of  the  visual 
sense.     This  explanation  of  hallucination  is  correct  only 


GENERAL  PATHOLOGY  43 

inasmuch  as  a  hallucination  is  indeed  a  sensation  not 
originating  from  an  external  object,  but  the  explanation 
is  not  sufficient  since  it  would  justify  designating  every 
memory  image  as  a  hallucination.  For  a  memory  image  is 
also  a  sensation  not  originating  from  an  external  object. 
A  more  exhaustive  definition  must,  therefore,  be  sought. 
It  is  conceivable  that  a  sensation  may  be  neither  induced 
from  the  periphery,  nor  brought  about  by  way  of  asso- 
ciation like  a  memory  image  (p.  9),  but  may  originate 
in  the  brain  cortex  at  the  place  where  the  impressions 
are  stored  up.  If  a  pathological  irritation  be  active  at 
this  place,  it  will  cause  sensations  to  arise  which  will 
have  no  relation  to  an  external  object  nor  to  the  associa- 
tion paths.  To  illustrate  the  point  in  a  trivial  manner, 
suppose  it  were  possible  to  prick,  with  a  needle,  certain 
parts  of  the  brain  cortex.  The  individual  would  have 
sensations  called  forth  by  this  artificial  injury  to  his 
brain.  These  sensations  would  correspond  to  the  im- 
pressions stored  up  in  the  injured  cerebral  part,  and 
would  appear  to  him  to  come  from  the  periphery,  from 
a  sense  organ,  for  he  is  unaware  of  the  injury  inflicted 
upon  his  brain.  Now,  substitute  for  this  artificial  injury 
a  pathological  irritation,  such  as  a  local  inflammation  of 
the  cerebral  cortex,  and  it  will  readily  be  seen  that  in  the 
consciousness  of  the  individual  sensations  must  arise 
which  he  believes  to  come  from  a  sense,  but  which  in 
reality  have  no  relation  to  the  periphery  nor  to  the  asso- 
ciation paths.  The  definition  of  hallucination  is,  there- 
fore, the  following:  Every  sensation  originating,  ac- 
cording to  the  patient's  conviction,  from  a  sense  organ, 
but  in  reality  not  called  forth  at  the  periphery,  further 
every  memory  image  arising  in  consciousness  not  by  way 
of  the  association  paths,  is  a  hallucinatory  image;  every 


44  PSYCHE 

perception  composed  of  hallucinatory  images  (p.  12)  is 
a  hallucinatory  perception  or  simply  a  hallucination. 

Illusion  is  closely  related  to  hallucination.  In  every- 
day language  this  word  is  often  used  to  express  an  in- 
adequate perception.  We  sometimes  say  one  has  been 
under  an  illusion  when,  for  instance,  walking  on  the 
street  he  believes  to  see  an  acquaintance,  but  on  approach- 
ing finds  that  it  is  some  one  else.  In  a  psychiatrical  sense, 
however,  this  is  no  illusion,  but  merely  a  superficial  per- 
ception. Illusion,  as  a  medical  term,  signifies  an  actual 
sensation  during  which  the  patient  hallucinates,  a  real 
perception  interfered  with  by  the  supervening  of  a  hallu- 
cination. One  who  is  subject  to  hallucinations  is  liable 
to  have  illusions  at  any  moment.  If  he  were  put  into  a 
dark  room  where  he  sees  nothing  and  hears  nothing,  he 
would  have  pure  hallucinations.  But  when  he  is  on  the 
street  where  he  sees  objects  and  hears  noises,  his  hallu- 
cinatory sensations  will  combine  with  actual  sensations 
to  form  illusions.  He  will  see,  for  instance,  persons,  but 
in  cadaverous  appearance  or  in  queer  colors ;  he  will  hear 
noises,  but  terribly  loud,  etc.  It  is  evident  that  such  a 
perception  is  very  different  from  what  is  sometimes  called 
illusion  in  ordinary  language.  If  one  imagines  he  sees 
an  acquaintance  and  finds  later  that  he  has  been  mistaken, 
this  is  merely  a  deficient  observation,  the  capability  of 
the  senses  not  having  been  sufficient  for  the  right  per- 
ception. In  the  hallucination  as  well  as  in  the  illusion 
one  hallucinates,  but  in  the  latter  at  the  moment  of  an 
actual  sensation.  A  patient,  for  instance,  stated  that  he 
saw  on  the  street  a  person  with  a  golden  halo  around  his 
head.  This  was  an  illusion;  he  saw  somebody,  and  in 
the  same  moment  he  hallucinated  in  the  visual  sense. 

Hallucinations  occur  in  all   the  senses,   most   fre- 


GENERAL  PATHOLOGY  45 

quently  in  the  senses  of  hearing  and  of  sight.  The  aud- 
itory hallucinations  seem  to  be  more  frequent  than  the 
visual  hallucinations. 

It  is  comprehensible  that  after  the  loss  of  a  certain 
sense,  hallucinations  relating  to  that  sense  can  take  place. 
For  the  loss  of  a  sense  does  not  imply  the  extinction  of 
the  impressions  stored  up  in  the  brain  through  this  sense. 
The  impressions  remain  in  the  cerebral  cortex  and  may 
give  rise  to  hallucinations.  And  indeed,  it  is  often  ob- 
served that  patients  with  acquired  blindness  hallucinate 
quite  a  good  deal  in  the  visual  sense  when  suffering  from 
a  psychosis.  The  same  is  the  case  with  the  sense  of  hear- 
ing. But  illusions  can  never  occur  in  the  sphere  of  a  lost 
sense.  For  illusions  are  combinations  of  actual  and  hal- 
lucinatory sensations;  the  former,  however,  are  done 
away  with  by  the  loss  of  the  sense. 

According  to  a  general  biological  law  there  is  no 
sharp  limit  between  the  normal  and  pathological.  The 
limit,  geometrically  expressed,  is  not  a  line,  but  a  zone, 
the  so-called  physiological  latitude.  This  law  applies 
also  to  the  distinction  of  normal  memory  images  from 
hallucinatory  images.  Between  both  there  are  gradual 
transitions.  In  recollecting  a  shot  the  auditory  memory 
image  is  comparatively  weak.  It  is  far  from  having  the 
intensity  of  the  auditory  sensation  actually  received  when 
hearing  the  shot.  But  there  are  people  in  whom  the 
memory  images  are  much  keener  than  in  the  average 
person.  An  ingenious  musician  remembers  a  melody 
with  great  vividness,  he  almost  hears  it.  Great  artists, 
thinking  of  the  picture  they  want  to  paint,  have  it  before 
their  very  eyes.  There  are,  therefore,  even  in  sane 
people  considerable  differences  in  the  intensity  of  mem- 
ory images.     If,  however,  a  pathological  irritation  be 


46  PSYCHE 

active  at  the  place  where  sense  impressions  are  stored  up, 
images  arise  in  consciousness  as  vivid  as  actual  sensa- 
tions. They  are  spoken  of  as  hallucinations  while  this 
term  is  not  applied  to  the  extremely  vivid  memory  im- 
ages of  sane  persons.  For  there  is  a  great  difference 
between  the  two  instances  aside  from  the  non-participa- 
tion of  the  association  paths  in  one  instance  and  their  co- 
operation in  the  other.  The  sane  person,  be  his  memory 
images  ever  so  vivid,  is  still  conscious  that  he  is  dealing 
with  nothing  else  but  memory  images,  with  ideas  arising 
very  strongly  within  him.  The  diseased  individual,  how- 
ever, does  not  recognize  his  memory  images  as  such,  but 
believes  to  have  actual  sensations  coming  from  the  peri- 
phery, from  a  sense  organ. 


Chapter  XXII. 
AUDITORY  HALLUCINATIONS. 

The  auditory  hallucinations  are  the  most  frequent. 
For  by  the  sense  of  hearing  most  of  the  experiences  in 
life  are  acquired.  More  auditory  memory  images  are, 
therefore,  deposited  in  the  cerebral  cortex  than  memory 
images  obtained  through  any  other  sense. 

Patients  whose  acoustic  memory  images  are  differ- 
ent from  the  normal  memory  images  of  sound,  are  not 
yet  afflicted  with  auditory  hallucinations.  Between  the 
normal  auditory  memory  images  and  auditory  hallucina- 
tions there  are  gradual  transitions.  Some  patients  com- 
plain that  a  word  or  a  melody  which  they  are  merely 
thinking  about  appears  to  them  very  vivid.  But  their 
memory  images  are  still  sufficiently  faint,  far  from  be- 
ing equivalent  to  spoken  words.     The  patients  still  know 


GENERAL  PATHOLOGY  47 

that  another  person  cannot  hear  their  memory  images. 
This  is  the  first  step  leading  to  pathological  conditions, 
but  still  met  with  normally.  In  the  next  grade  patients 
say  they  hear  their  thoughts  so  loudly  that  they  are  under 
the  impression  that  others  standing  very  near  may  also 
hear  them,  but  they  are  not  as  well  perceptible  as  words 
spoken  aloud.  Again  other  patients  complain  of  their 
thoughts  becoming  so  loud  that  people  passing  by  can 
hear  them.  They  maintain  that  their  thoughts  are  re- 
peated by  others.  Reading  silently  they  hear  everything 
repeated  as  though  others  would  read  with  them.  But 
although  these  acoustic  memory  images  are  of  such  in- 
tensity that  they  are  not  distinguishable  from  actual  au- 
ditory sensations,  the  patients  are  yet  conscious  that  they 
are  their  own  thoughts,  i.  e.,  they  are  still  sensations 
brought  about  by  way  of  association.  Other  patients 
finally  assert  they  hear  words  originating  from  without, 
and  are  certain  that  they  are  not  their  own  individtial 
thoughts.  They  have  auditory  sensations,  the  origin  of 
which  they  refer  to  the  outside  world,  but  which  in  re- 
ality originate  in  their  own  brain  cortex,  at  the  seat  of 
tlie  auditory  sense  impressions.  Such  patients,  therefore, 
are  suffering  from  true  hallucinatory  sensations.  The 
last  example  illustrates  purely  pathological  conditions, 
while  the  preceding  examples  refer  to  the  transitional 
stages  between  the  normal  and  pathological. 

The  auditory  hallucinations  show  the  same  variation 
in  intensity  as  the  normal  sensations  of  hearing.  One 
maj  hear  something  spoken  in  a  whisper,  or  uttered 
aloud,  or  something  may  be  thundered  into  one's  ear. 
Likewise  the  auditory  hallucinations  vary.  Their  in- 
tensity may  be  as  slight  as  that  of  memory  images  of 
hearing.     The  patients  commence  to  notice  that  some- 


48  PSYCHE 

thing  is  being  ''suggested"  to  them.  They  are  convinced 
that  it  is  no  thought  of  their  own,  no  memory  image; 
for  it  does  not  at  all  appertain  to  their  thoughts,  forms 
no  part  of  them.  It  appears  to  the  patients  that  ideas 
not  their  own  are  infused  into  their  mind.  They  arrive 
at  the  notion  that  suggestions  are  imparted  to  them  by 
a  superior  power,  by  God  or  the  Evil  One,  according  to 
the  contents  of  the  suggestions.    In  the  next  grade  hallu- 


Fig.  6. 

When  the  retina,  R,  is  stimulated,  the  irritation  is  conveyed 
through  the  optic  nerve,  on  to  the  visual  center,  vs.  It  may- 
travel  further  through  the  association  path,  ai,  to  the  audi- 
tory center,  as,  and  call  forth  an  auditory  image.  The  in- 
tensity of  this  image  may  be  abnormal,  but  the  way  ai,  by 
which  it  has  been  awakened  is  used  also  under  normal  con- 
ditions. 

cinating  patients  say  they  hear  words  spoken  in  a  whisper, 
or  at  a  great  distance,  or  near  by  and  in  an  ordinary  tone 
of  voice.  Other  patients,  finally,  relate  that  words  are 
violently  shouted  into  their  ears,  or  they  hear  walls  crash- 


GENERAL  PATHOLOGY  49 

ing  with  terrific  din  or  the  roar  of  cannons.     These  are 
auditory  hallucinations  of  greatest  intensity. 

Patients  who  complain  about  their  thoughts  becom- 
ing loud  are  not  diseased  to  the  same  extent  as  those 
having  pronounced  hallucinations,  even  if  the  latter  have 
only  the  low  intensity  of  memory  images.  For  in  the 
first  instance  the  patients  have  sensations  which  are  noth- 
ing else  but  memory  images  of  unusual  intensity  and 
come  by  a  way  also  used  under  normal  conditions  (Fig. 
6,  ai) ;  in  the  second  instance,  however,  the  sensations 
of  the  patients  arise  in  a  cerebral  part  (as)  where  nor- 
mally sensations  never  take  their  origin. 


Chapter  XXIIL 

VISUAL  HALLUCINATIONS. 

Similar  conditions  prevail  in  the  sense  of  sight. 
Some  persons  assert  that  a  picture  which  they  are  thinking 
of  appears  to  them  as  vivid  as  though  they  would  really 
see  it.  Yet  they  are  conscious  that  it  is  merely  a  memory 
image.  This  great  vividness  of  the  visual  memory  im- 
ages represents  the  transition  to  pathological  conditions. 
In  pronounced  visual  hallucinations  the  patients  say  they 
see  things  before  them  which  in  reality  are  not  present. 
The  visual  hallucinations  show  the  same  gradations  as 
the  auditory  hallucinations.  Some  patients  say  something 
flutters  past  their  eyes,  or  they  see  shadows,  things  of 
vague  shape  and  indeterminate  color,  without  form,  flat, 
hazy,  gray.  When  the  visual  hallucinations  are  stronger, 
the  patients  perceive  persons  and  objects  of  distinct  shape 
and  definite  color,  red,  green,  or  blue.  Such  hallucina- 
tions do  not  differ  any  more   from  actual   sensations. 


50  PSYCHE 

Other  patients  finally  see  flames,  burning  structures, 
flashes  of  lightning,  etc.  These  are  visual  hallucinations 
of  maximum  intensity. 

Visual  deceptions  different  from  those  just  men- 
tioned are  the  following:  Patients  relate  that  they  see 
figures  changing  their  sizes.  In  the  beginning  the  figures 
appear  big,  then  they  become  smaller  and  smaller,  and 
at  last  they  fade  away  entirely.  In  other  patients  the 
apparitions  are  inverse.  They  begin  to  perceive  animals 
and  things  of  minute  size.  After  a  while  these  change 
into  immense  masses  or  huge  monsters.  With  such  hal- 
lucinations is  connected  a  perception  of  movement.  When 
a  patient  sees  a  figure  growing  bigger,  he  believes  that  it 
approaches  towards  him;  he  notices  something  coming- 
nearer  and  nearer  until  it  finally  penetrates  into  him. 
Such  deceptions  give  rise  to  the  belief  in  devilry.  An- 
other visual  deception  consists  in  seeing  a  multitude  of 
things,  of  many  threads,  gnats,  beetles,  mice,  etc.  Some 
patients  see  many  objects  in  motion,  rats  jumping  about, 
insects  fluttering,  little  men  dancing,  etc.  (delirium  tre- 
mens, p.  260). 


Chapter  XXIV. 

TACTILE,  OLFACTORY,  AND  GUSTATORY  HALLU= 
CINATIONS. 

Next  in  frequency  are  the  hallucinations  of  the  tac- 
tile sense.  Some  patients  tell  of  being  gently  touched, 
of  formication;  others  complain  of  intense  pressure  on 
various  parts  of  the  body  or  of  having  been  shot.  Again 
others  report  that  the  roof  of  their  scull  has  been  lifted 
away  and  their  brain  is  exposed;  they  beg  pitifully  not 
to  be  touched  on  the  head  or  shaken  in  any  manner, 


GENERAL  PATHOLOGY  51 

Some  patients  feel  as  though  dust  were  constantly  falling 
on  them  from  the  air,  and  cover  themselves  to  prevent 
it  from  reaching  their  body.  Sexual  deceptions  are  also 
to  be  mentioned  here.  Female  patients  relate  accounts 
of  having  been  criminally  assaulted. 

In  the  sense  of  smell  hallucinations  are  frequently 
met  with.  Some  patients  perceive  cadaverous  odors. 
Such  hallucinations  lead  the  patients  to  the  delusion  of 
being  on  a  graveyard  or  of  having  eaten  human  flesh, 
and  the  like.  Other  patients  scent  brimstone  everywhere. 
They  bring  this  into  relation  to  the  devil  who  according 
to  folklore  spreads  a  sulphurous  odor.  Other  patients 
again  complain  of  smelling  burnt  stufY,  such  as  singed 
hair,  etc.  Also  agreeable  perfumes  are  perceived  by 
some  patients.  They  imagine  that  they  inhale  an  atmo- 
sphere of  a  finer  fragrance  than  others. 

Regarding  the  sense  of  taste  it  is  often  difficult  to 
decide  whether  hallucinations  attributed  to  it  do  not  be- 
long rather  to  the  sense  of  smell.  For  when  a  patient,  for 
instance,  says  something  has  a  putrid  taste,  this  may  also 
be  an  olfactory  deception.  Frequently  patients  complain 
that  their  food  has  a  metallic  taste,  as  of  copper.  Other 
patients  perceive  a  bitter,  salty  taste,  etc.  Gustatory  hal- 
lucinations may  lead  the  patients  to  the  delusion  that 
poison  has  been  put  into  their  food. 


Chapter  XXV. 

SEQUELAE     AND     SYMPTOMS     OF     HALLUCINA= 

TIONS. 

A  patient  may  hallucinate  in  more  than  one  sense. 
In  delirium,  for  instance,  hallucinations  take  place  in  all 
the  senses.    It  is  evident  that  such  a  patient  must  become 


52  PSYCHE 

entirely  confused.  For  the  things  that  he  sees  do  not 
exist,  the  words  that  he  hears  are  not  spoken,  and  so  on. 
One  consequence  of  hallucinations,  especially  when  they 
are  manifold,  is,  therefore,  a  state  of  confusion.  Delu- 
sions and  violent  acts  form  another  important  sequence 
of  hallucinations.  The  patient  draws  conclusions  from 
his  hallucinations  in  the  same  manner  as  a  sane  person 
from  his  normal  sensations.  When  he  hears  abusive 
words,  he  concludes  that  somebody  is  insulting  him,  and 
is  misled  to  commit  an  assault  upon  a  supposed  enemy. 
Hallucinations  have  so  great  an  effect  upon  the  patient 
that  he  obeys  them  more  promptly  than  his  real  percep- 
tions. Many  offenses  committed  by  the  insane  are  to  be 
attributed  merely  to  hallucinations.  The  reason  that  hal- 
lucinations have  a  greater  influence  on  patients  than  nor- 
mal sensations  is  that  the  former  are  founded  on  patho- 
logical processes,  and  these  are  often  of  greater  intensity 
than  the  normal  sensational  processes.  While  a  patient 
hallucinates  his  normal  perceptions  are  forced  into  the 
background.  Just  as  a  strong  normal  sensation  causes  a 
person  to  direct  his  attention  to  the  object  producing  the 
sensation  and  to  overlook  everything  else,  so  also  a  hal- 
lucination, owing  to  its  greater  intensity,  absorbs  com- 
pletely the  attention  of  the  patient  and  prevents  him  from 
becoming  aware  of  other  sensations.  This  monopolizing 
of  the  patient's  attention  characterizes  hallucinations.  In 
the  midst  of  a  conversation  we  notice  that  all  of  a  sudden 
the  patient  assumes  an  air  of  pensiveness  or  absent- 
mindedness  and  does  not  listen  any  more  to  the  words 
directed  to  him.  This  abrupt  distraction  is  a  fairly  sure 
sign  that  at  this  very  moment  hallucinations  have  arisen 
in  the  patient's  consciousness,  attracting  all  his  attention. 


GENERAL  PATHOLOGY  53 

Chapter  XXVL 
DELUSIONS. 

The  most  important  morbid  phenomena  in  the  idea- 
tional sphere  are  the  delusions.  For  by  this  symptom 
more  than  by  anything  else  the  patients  attract  the  atten- 
tion of  neighbors  and  relatives  and  are  recognized  as 
insane. 

Laymen  care  less  for  essential  features  of  delusions 
than  for  the  casual  sign  that  they  often  contain  a  palpable 
absurdity.  They  are  ready  with  their  judgment  when 
they  hear  an  irrational  utterance.  The  physician  cannot 
assume  such  a  standpoint.  For  otherwise  he  would  be 
unable  to  differentiate  malingery  from  disease,  which  is 
very  important,  especially  in  forensic  matters.  To  be 
able  to  detect  the  wiles  of  an  impostor  he  must  have  a 
more  profound  conception  of  delusions  and  must  be 
guided  by  unmistakable  criteria.  These  are  obtained  by 
considering  the  origin,  the  source  of  delusions,  by  prov- 
ing that  their  genesis  is  pathological. 

The  principal  source  of  delusions  are  hallucinations 
and  illusions.  These  impart  to  the  patient  certain  notions 
in  the  same  way  as  a  sane  person  draws  conclusions  from 
his  normal  perceptions.  The  conclusions  derived  from 
hallucinations  and  illusions  represent  delusions.  An  error 
is  far  from  being  a  delusion.  One  often  errs  in  life, 
owing  to  superficial  observation  or  to  lack  of  experience. 
Only  when  a  notion,  be  it  true  or  not,  can  be  shown  to 
have  its  origin  in  hallucinations,  is  it  to  be  designated 
as  a  delusion.  Delusions  may  contain  a  truth.  For  ex- 
ample, a  patient  took  the  notion  that  his  father  was  dead, 
which  was  not  the  case.  According  to  laymen's  concep- 
tions this  is  at  once  a  delusion.    But  the  physician  has  to 


54  PSYCHE 

prove  first  that  the  patient  is  suffering  from  hallucina- 
tions before  he  is  justified  in  assuming  a  delusion.  The 
importance  of  such  a  proof  is  seen  by  what  followed. 
After  a  lapse  of  some  time  the  father  died,  and  the  son's 
notion  thus  became  true.  Laymen  would  say  the  patient 
was  now  free  from  his  delusion,  but  from  a  psychiatrical 
point  of  view  the  delusion  is  still  present,  although  now 
it  contains  a  truth. 

Another  source  of  delusions  lies  in  morbid  altera- 
tion of  the  affective  state.  Suffering  from  morbid  de- 
pression, the  patient  sees  everything  in  an  unfavorable 
light,  for  only  such  memory  images  arise  in  his  con- 
sciousness which  have  been  produced  by  painful  sensa- 
tions (pp.  20,  34).  Working  with  such  memory  images, 
he  acquires  sad  perceptions.  The  presence  and  future 
appear  gloomy  to  him,  he  underestimates  his  capabilities 
and  his  circumstances,  believes  himself  to  be  despised 
and  persecuted,  to  be  lost  forever.  These  are  delusions 
of  a  depressive  jiature. 

On  the  other  hand,  when  laboring  under  morbid 
exaltation,  only  memory  images  of  a  cheerful  character 
arise  in  the  consciousness  of  the  patient  (pp.  20,  36). 
This  leads  him  to  conclusions  which  deceive  him  regard- 
ing his  powers,  he  overestimates  his  capabilities  and  his 
circumstances.     These  are  delusions  of  exaltation. 

When,  therefore,  in  a  given  instance  it  is  possible 
to  demonstrate  that  a  notion  formed  by  the  patient  is 
founded  on  hallucinations  or  illusions,  or  on  a  morbid 
alteration  of  the  affective  state,  this  notion  is  to  be  con- 
sidered a  delusion. 


GENERAL  PATHOLOGY  55 

Chapter  XXVIL 

CLASSIFICATION,      DIAGNOSTIC      VALUE,      AND 
SEQUELAE   OF    DELUSIONS. 

Formerly  innumerable  sorts  of  delusions  were  dis- 
tinguished. Indeed,  everybody  produces  delusions  pecu- 
liar to  his  character,  education,  and  calling  in  life.  The 
delusions  of  the  army  officer,  for  instance,  will  differ 
from  those  of  the  priest.  To  obtain  a  proper  guidance  in 
the  great  variety  of  delusions  it  is  best  to  classify  them 
so  that  the  diagnosis  of  the  psychoses  may  be  facilitated. 
Accordingly  the  following  delusions  may  be  distin- 
guished: I.  Delusions  of  grandeur  ^Grossenwahn," 
megalomania)  ;  2.  delusions  of  self -depreciation  ("Klein- 
heitswahn,"  micromania)  ;  3.  delusions  of  furtherance 
( "Forderungs wahn" ) ,  i.  e.,  of  being  the  object  of  favor 
or  bounty  from  persons  in  high  position,  through  super- 
natural powers,  or  even  through  propitious  circumstances ; 
4.  delusions  of  grievance  (''Beeintrachtigungswahn"), 
i.  e.,  of  being  wronged  or  of  innocently  suffering  injuries. 
Delusions  may  be  fixed,  i.  e.,  irremediable,  or  they  may 
still  be  capable  of  correction.  A  distinction  can  also  be 
made  according  to  the  explanation  which  the  patient  ad- 
vances for  his  delusions.  A  fairly  plausible  reason  may 
l)e  brought  forward  by  the  patient  for  his  delusions,  or 
he  may  give  a  very  inadequate  reason  for  them  or  no 
reason  at  all.    The  latter  are  called  absurd  delusions. 

This  classification  of  the  delusions  is  of  great  diag- 
nostic value.  All  delusions  of  grandeur  are  characteristic 
of  maniacal  excitatory  states.  In  such  conditions  we 
never  fail  to  observe  that  the  patient  overestimates  him- 
self, his  present  circumstances,  and  his  future.  If  he  is 
able  to  state  some  plausible  reason  for  his  exalted  no- 


56  PSYCHE 

tions,  he  is  suffering  from  ordinary  maniacal  excitement, 
but  if  no  explanation  is  advanced  by  the  patient  for  his 
delusions  of  grandeur,  paretic  excitement  or  dementia 
praecox  is  to  be  surmised;  in  other  words,  absurd  delu- 
sions of  grandeur  indicate  general  paresis  or  dementia 
praecox.  Something  analogous  applies  to  the  delusions 
of  self -depreciation.  They  are  pathognomonic  of  melan- 
cholic states.  If  they  are  fairly  well  accounted  for  by 
the  patient,  we  are  dealing  with  a  melancholia  of  slight 
intensity  and  of  a  comparatively  favorable  prognosis.  If 
however  the  delusions  bear  the  stamp  of  absurdity,  gen- 
eral paresis  or  dementia  praecox  may  be  assumed.  The 
delusions  of  furtherance  and  of  grievance  are  character- 
istic of  paranoia. 

That  the  conduct  of  the  patient  is  greatly  influenced 
by  his  delusions  is  evident.  As  the  sane  person  is 
prompted  to  act  in  conformity  with  his  convictions,  to 
offer  sacrifices  for  them,  and  not  to  abandon  them  with- 
out good  cause,  so  also  a  patient  is  prone,  we  may  rather 
say,  compelled,  to  conform  his  actions  to  his  delusions. 
Before  long  he  begins,  driven  by  their  compelling  force, 
to  commit  acts  which  bring  him  into  conflict  with  his 
neighbors.  Owing  to  delusions,  crimes  of  the  worst  sort 
may  be  perpetrated  by  the  patients.  Such  actions  dic- 
tated by  delusions  are  to  be  regarded  as  performed  in  a 
state  of  want  of  freedom  of  the  will.  For  the  physician 
has  to  consider  any  action  as  involuntary  which  he  can 
demonstrate  to  originate  from  pathological  factors 
(p-25). 


GENERAL  PATHOLOGY  57 

Chapter  XXVIIL 
DIFFERENTIATION   OF   THE   DELUSIONS. 

Delusions  of  furtherance  may  be  easily  confounded 
with  those  of  grandeur,  and  delusions  of  grievance  with 
those  of  self-depreciation.  An  exact  distinction  is,  there- 
fore, required  because  of  the  diagnostic  importance  (p.  55  ) 
of  the  different  forms  of  delusions.  This  distinction 
is  obtained  by  inquiring  into  the  role  which  the  patient's 
self,  his  ego,  plays  in  the  delusion.  When,  for  instance, 
the  patient  says  he  will  soon  ascend  the  throne  of  Brazil, 
this  assertion  may  be  a  delusion  of  grandeur  as  well  as 
of  furtherance.  If  the  patient  maintains  that  he  is  able 
to  conquer  the  throne  through  his  great  wisdom  and 
power,  he  is  laboring  under  a  delusion  of  grandeur.  It 
is  the  patient's  own  self  that  is  great  and  mighty.  If 
however  he  says  he  is  descended  from  parents  who  have 
a  claim  to  the  throne,  he  is  suffering  from  a  delusion  of 
furtherance.  The  essential  element  furthering  the  patient 
lies  in  his  birth.  If  a  patient  says  he  will  obtain  great 
wealth  because  of  being  the  protege  of  a  powerful  prince, 
he  has  a  delusion  of  furtherance.  But  if  he  maintains  to 
possess  millions  because,  through  his  great  cleverness,  he 
has  discovered  the  art  of  making  gold,  he  suffers  from 
a  delusion  of  grandeur.  If  a  patient  says  he  has  been 
chosen  by  God  to  redeem  the  sinful  world,  he  has  a  delu- 
sion of  furtherance.  If  however  he  maintains  to  possess 
unlimited  divine  power  enabling  him  to  bring  order  and 
rule  into  this  wicked  world,  he  is  possessed  by  a  delusion 
of  grandeur. 

The  same  relation  prevails  between  the  delusions  of 
grievance  and  those  of  self-depreciation.  Some  patient 
harbors  the  intention  of  suicide.     He  says  he  is  exposed 


58  PSYCHE 

to  intolerable  persecution  so  that  he  is  disgusted  with 
life,  that  life  has  no  attraction  for  him  any  more.  To 
say  simply  the  patient  suffers  from  a  delusion  of  per- 
secution would  not  clear  up  the  diagnosis.  We  must 
try  to  find  out  what  the  patient  thinks  of  his  own  self. 
If  he  says  that  he  is  unworthy,  that  he  deserves  no  better 
treatment  from  those  around  him,  that  persecutions  still 
worse  ought  to  be  his  share,  he  labors  under  a  delusion  of 
self-depreciation.  For  the  patient's  self  plays  a  guilt- 
laden  role  and  is  worthless  and  despicable.  If  however 
the  patient  says  that  he  is  entirely  innocent,  that  he  does 
not  understand  at  all  why  he  should  be  the  object  of 
malicious  oppression,  he  is  swayed  by  a  delusion  of  griev- 
ance.    For  he  still  values  his  ego  a  great  deal. 


Chapter  XXIX. 
SYSTEMATIZED  DELUSIONS. 

When  delusions  of  furtherance  and  of  grievance 
exist  concomitantly,  the  diagnosis  paranoia  may  be  made 
with  more  certainty  than  when  the  patient  manifests  only 
one  kind  of  these  delusions.  Between  the  two  varieties 
of  delusions  there  is  often  a  palpable  contradiction  which 
the  patient  may  be  aware  of  and  which  he  tries  to  ex- 
plain away.  The  patient,  for  instance,  says  he  will  soon 
ascend  the  throne  of  Brazil,  to  which  he  is  entitled  by 
birth.  He  thus  suffers  from  a  delusion  of  furtherance. 
At  the  same  time  he  maintains  to  be  maliciously  perse- 
cuted. This  inconsistent  assertion  that  so  high  a  per- 
sonage as  a  future  emperor  should  be  the  object  of  op- 
pression, is  explained  by  the  patient  in  the  following 
way:    There  are  other  pretenders  to  the  throne  who  are 


GENERAL  PATHOLOGY  59 

trying  to  prevent  him  from  obtaining  his  rights,  who  are 
seeking  after  his  life,  and  who  are  contriving  all  the  per- 
secutions which  he  is  exposed  to.  This  weighing  and  ad- 
justing of  different  notions,  this  effort  to  solve  apparent 
contradictions  between  them,  are  called  systematized  de- 
lusion. It  is  pathognomonic  of  paranoia.  Patients  labor- 
ing under  systematized  delusions  would  retrospectively 
change  their  whole  past  to  bring  it  in  accord  with  their 
present  notions.  In  this  way  arise  the  romantic  tales 
of  some  patients  relating  to  their  birth,  their  early  youth, 
their  education,  etc.  (p.  178). 


Chapter  XXX. 

FIXED  DELUSIONS. 

It  is  very  important  to  have  an  exact  knowledge  of 
the  so-called  fixed  delusions,  a  diagnosis  of  great  signifi- 
cance being  established  when  they  are  demonstrated.  A 
patient  with  fixed  delusions  is  suffering  from  secondary 
insanity,  which  forms  the  continuation  or  the  incurable 
terminal  stage  of  primary  insanity  (pp.  181,  184).  Since 
so  ominous  a  prognosis  is  furnished  by  the  presence  of 
fixed  delusions,  an  accurate  understanding  of  what  is 
meant  by  the  term  is  required.  Many  a  delusion  may 
last  very  long,  for  weeks  and  months;  still  it  is  not  a 
fixed  delusion.  It  may  finally  be  supplanted  by  another 
delusion  or  abandoned  entirely  after  having  been  recog- 
nized by  the  patient  as  a  wrong  notion.  If  however  a 
patient  clings  to  a  delusion  for  years,  we  would  perhaps 
be  justified  in  regarding  it  as  a  fixed  delusion.  But  the 
duration  of  a  delusion  cannot  be  taken  as  a  criterion  for 
its  being  fixed.    For  there  is  no  essential  point  available 


6o  PSYCHE 

for  establishing  the  limit  of  time  beyond  which  a  delu- 
sion must  have  lasted  to  be  justly  considered  a  fixed  delu- 
sion. While  some  would  find  this  limit  in  a  few  months, 
others  would  not  regard  even  several  years  as  a  sufficient 
time  limit.  A  more  reliable  criterion,  therefore,  is  neces- 
sary. This  is  readily  found  when  the  source  of  delusions 
is  taken  into  consideration.  The  absence  of  the  factors 
which  produce  delusions  is  an  unmistakable  sign  that  the 
delusions  are  fixed.  When  there  are  no  more  hallucina- 
tions and  illusions,  and  the  affective  state  of  the  patient 
is  entirely  normal  (pp.  53-54),  and  he  still  clings  to  his 
former  wrong  notions,  they  have  become  fixed  delusions, 
the  patient  being  mentally  so  enfeebled  by  the  preceding 
psychosis  that  he  is  unable  to  recognize  his  delusions  as 
such  and  to  abandon  them.  Had  the  psychosis  not  term- 
inated in  mental  weakness,  the  patient  would  have  given 
up  his  delusions. 


Chapter  XXXL 
DISTURBANCE  OF  MEMORY  IN  GENERAL. 

Memory  is  the  capability  of  producing  ideas  by  way 
of  association.  For  this  end  sensations  must  have  been 
received  and  must  have  left  impressions  in  the  sensory 
elements  of  the  brain  cortex,  these  elements  must  be  ana- 
tomically connected  with  each  other,  and  the  association 
paths  must  be  conductive. 

Manifold  disturbances  occur  in  the  activity  of  the 
memory.  Some  of  them  are  especially  worthy  of  note, 
as  the  abnormally  increased  capacity  of  memory,  hyper- 
mnesia,  and  the  diminished  capacity  of  memory,  hypo- 
mnesia  and  amnesia.   The  capacity  of  memory  is  not  the 


GENERAL  PATHOLOGY  6i 

same  in  different  healthy  persons,  it  varies  even  in  one 
and  the  same  person  according  to  the  state  of  fatigue 
or  rest  and  according  to  age.  In  youth  impressions  are 
more  readily  received  and  events  more  easily  recalled, 
in  advanced  age  both  these  faculties  decrease.  As  a 
compensation  the  person,  mature  in  years,  aids  his  mem- 
ory by  understanding  and  reasoning,  finds  by  inference 
how  an  event  probably  came  about.  A  young  person, 
for  instance,  can  remember  exactly  that  he  did  not  make 
a  certain  remark  attributed  to  him ;  a  person  advanced 
in  years  may  not  be  positive  about  this  by  virtue  of  his 
memory,  but  by  an  operation  of  the  understanding  he 
will  arrive  at  the  conclusion  that  such  words  could  not 
possibly  have  been  uttered  by  him. 


Chapter  XXXIL 

ABNORMALLY    INCREASED    CAPACITY    OF 
MEMORY. 

In  all  maniacal  states  the  capacity  of  memory  is 
temporarily  increased,  owing  to  the  facility  of  associa- 
tion (pp.  19-20,  and  Ch.  16,  p.  35).  It  must  be  assumed 
that  in  maniacal  conditions  many  mental  processes  are 
intensified.  For  this  reason  the  resistance  in  the  asso- 
ciation paths  is  more  easily  overcome.  When  the 
maniacal  excitement  is  at  an  end,  the  increase  of  the 
capacity  of  memory  also  ceases.  This  is  not  to  be  re- 
garded as  due  to  fatigue  brought  about  by  the  enhanced 
work  of  the  memory  during  the  preceding  maniacal  ex- 
citement. For  there  are  psychoses  in  which  maniacal 
states  alternate  very  frequently,  even  daily,  with  melan- 
cholic ones.     In  these  cases  we  observe  a  lowering  of  the 


62  PSYCHE 

capacity  of  memory  with  the  beginning  of  the  melan- 
cholic state  and  a  rising  with  the  onset  of  the  maniacal 
excitement,  both  too  prompt  to  be  attributed  respectively 
to  fatigue  and  restoration. 

A  patient  in  maniacal  excitement  is  aware  of  the 
improvement  of  his  memory  and  thinks  that  he  has  be- 
come more  clever  than  he  ever  was. 

Besides  the  transitory  improvement  of  memory  in 
maniacal  states  there  is  a  permanent  hypermnesia  which 
is  very  remarkable.  Individuals  who  are  intellectually 
backward  and  defective  in  their  affective  sphere  may  dis- 
play, so  to  say  as  a  compensation,  increased  capacity  of 
memory.  Such  compensation  is  often  observed  physio- 
logically. The  capacity  of  one  organ  is  sometimes  con- 
ditioned by  that  of  another  organ  or  another  group  of 
organs.  After  the  extirpation  of  one  kidney  the  other 
accomplishes  more  than  before.  The  organ  left  becomes 
larger,  hypertrophied,  and  its  efficiency  is  greatly  en- 
hanced. If  one  sense  has  not  been  developed  or  has  per- 
ished, another  sense  becomes  more  efficient.  The  hear- 
ing of  those  born  blind  is  remarkably  acute,  and  their 
tactile  sense  perhaps  more  so.  The  blind  know  whether 
they  are  approaching  a  wall;  one  may  say  they  "hear" 
the  wall,  and  this  probably  by  the  resonance  of  their 
steps  becoming  stronger  with  the  approach  towards  the 
wall.  Something  analogous  applies  to  the  capacity  of 
memory  in  individuals  whose  intellectual  development 
has  been  arrested.  As  a  compensation  for  the  deficit  in 
other  mental  faculties  the  memory  vicariously  possesses 
increased  capacity. 

The  permanent  hypermnesia  has  another  basis  than 
the  transitory  one  of  the  maniacs.  It  is  not  founded  on 
the  facility  of  the  association,  but  on  the  sensations  leav- 


GENERAL  PATHOLOGY  63 

ing  more  readily  impressions  in  the  cerebral  cortex  than 
is  normally  the  case  (pp.  7-8).  It  is  astonishing  what  a 
wonderful  memory  for  the  most  unimportant  trifles  is 
manifested  by  these  patients.  In  school  the  teachers  are 
surprised  about  their  faculties.  They  know  by  heart 
almost  everything  they  have  read.  In  the  elementary 
schools  they  often  make  excellent  progress,  and  even  in 
the  higher  schools  they  may  distinguish  themselves. 
Simply  by  reproducing  the  judgments  of  others  they 
create  the  impression  of  being  highly  intelligent.  Indi- 
viduals with  such  awe-inspiring  memories  are  like  a 
book,  like  a  dictionary.  We  may  say  they  decorate 
themselves  again  and  again  with  false  plumes. 

Such  individuals  may  be  recognized  as  mentally 
defective  only  by  deficiency  of  understanding  and  char- 
acter (Ch.  82,  p.  199). 

When  judging  individuals  with  exceptionally  great 
power  of  memory  in  legal  matters  it  is  necessary  to  take 
into  consideration  the  pathologically  enhanced  capacity 
of  memory.  Children  with  wonderful  memories  must 
not  be  regarded  at  once  as  highly  gifted.  Especially 
when  a  person  coming  from  a  family  in  which  insanity 
has  prevailed  displays  an  exceedingly  powerful  memory, 
his  mental  health  ought  to  be  well  taken  care  of.  For 
it  is  to  be  borne  in  mind  that  just  those  tainted  by  her- 
edity and  endowed  with  remarkable  memories  have  a 
strong  predisposition  to  mental  disease. 

The  abnormally  increased  capacity  of  memory  just 
described,  which  is  met  with  in  idiots,  subsists  all  through 
life  provided  no  acute  psychosis  supervenes. 


64  PSYCHE 

Chapter  XXXIII. 
DIMINISHED  CAPACITY  OF  MEMORY. 

In  contrast  to  the  maniacal  states,  the  capacity  of 
memory  is  reduced  in  all  melancholic  conditions,  owing 
to  the  difficulty  of  association  (pp.  19-20,  33).  This 
impairment  of  memory  is  transitory,  ceasing  with  the 
disappearance  of  the  depressed  mood. 

Permanent  reduction  of  the  capacity  of  memory, 
hypomnesia  or  amnesia,  may  be  based  on  the  sensations 
failing  to  leave  impressions  in  the  brain  cortex  (pp.  7-8). 
To  some  extent  this  is  physiologically  the  case  in  ad- 
vanced age.  Some  things,  as  names,  numbers,  do  not 
"cling"  any  more.  Pathologically  the  failure  of  the 
sensations  to  leave  impressions  occurs  in  premature  and 
in  excessive  senescence.  The  patients  perceive  some- 
thing, and  in  the  next  moment  they  do  not  know  any- 
thing about  it.  They  peruse  the  newspaper,  and  yet  they 
do  not  know  what  they  have  read.  When  a  relative  or 
a  friend,  after  long  absence,  comes  into  their  home,  they 
embrace  him  joyfully.  When  thereupon  they  leave  the 
room  for  a  while,  they  forget  everything,  and  on  enter- 
ing the  room  again  and  noticing  the  friend,  their  joy 
bursts  out  anew,  as  if  they  would  see  him  for  the  first 
time.  This  experiment  may  be  repeated  several  times, 
and  in  this  way  such  patients  may  be  made  to  enjoy 
again  and  again  the  pleasure  of  seeing  a  dear  friend  after 
long  absence. 

Diminished  capacity  of  memory  based  on  the  same 
cause  as  the  hypomnesia  of  senility  is  met  with  in 
paretics  and  in  patients  suffering  from  secondary  de- 
mentia. The  patients  hear,  see,  etc.,  but  the  sensations 
leave  no  impressions, 


GENERAL  PATHOLOGY  65 

Another  form  of  amnesia  is  caused  by  destruction 
of  impressions  through  an  acut^  psychosis.  Memory 
suffers  through  a  mental  disease  in  the  same  way  as 
through  actual  loss  of  brain  substance.  Impressions  of 
the  sensations  are,  somehow  or  other,  formed  in  the 
brain  cortex — such  a  hypothesis  is  absolutely  indispens- 
able. Hence  an  operation  on  the  cerebral  cortex,  caus- 
ing loss  of  brain  substance,  will  necessarily  obliterate  a 
certain  sum  of  impressions.  The  individual  operated 
upon  is  by  no  manner  of  means  able  to  reproduce  the 
lost  impressions.  At  best  he  can  acquire  them  anew  by 
experiencing  again  the  corresponding  sensations.  Such 
a  condition  is  actually  created  by  apoplexies.  If  the  de- 
struction by  hemorrhage  of  brain  substance  has  taken 
place  in  that  cerebral  part  where  the  auditory  images 
are  stored  up,  aphasia  is  the  result.  The  patient  is  un- 
able to  speak  for  want  of  word  impressions,  the  repro- 
duction of  which  constitutes  speaking.  After  the  path- 
ological process  has  come  to  an  end  and  cicatrization  of 
the  injured  cerebral  part  has  come  about,  the  lost  audi- 
tory impressions  may  be  acquired  anew.  Such  extinction 
of  impressions  occurs  also  in  acute  mental  diseases  with- 
out hemorrhage  or  any  other  demonstrable  injury  to  the 
brain  cortex. 

In  general  paresis  both  forms  of  amnesia  mentioned 
above  are  met  with.  The  sensations  fail  to  leave  im- 
pressions, and  impressions  are  actually  destroyed  through 
gross  pathological  processes. 

A  third  form  of  amnesia  occurs  in  diseases  asso- 
ciated with  disturbance  of  consciousness.  The  memory 
at  any  rate  is  dependent  upon  the  lucidity  of  conscious- 
ness and  is  in  direct  proportion  to  it.  In  light  slumber 
events  are  not  remembered  as  well  as  in  a  waking  state, 


66  PSYCHE 

Patients  in  an  unconscious  condition  are  unaware  of 
what  is  going  on  around  them,  do  not  acquire  percep- 
tions, and  cannot  make  use  of  their  faculty  of  memory. 
After  awaking  they  cannot  remember  anything  that  has 
transpired  during  the  unconscious  state. 

Periods  of  unconsciousness  are  frequent  in  epilepsy. 
After  a  convulsive  seizure  the  patients  have  no  knowledge 
of  what  has  been  going  on  during  the  attack;  they  even 
do  not  know  that  they  have  had  an  attack,  finding  it  out 
only  through  some  injury  received  in  their  unconscious 
condition,  as  a  bite  on  the  lips  or  tongue  or  a  bleeding 
wound. 

Epileptic  patients  are  subject  to  spells  of  disturbance 
of  consciousness  without  convulsions.  These  periodic 
epileptic  spells  are  the  so-called  psychic  equivalents  of 
the  completely  developed  epileptic  attacks  (pp.  243-244). 
The  patients  do  not  fall  down,  seized  with  convulsions, 
but  walk  about  and  even  perform  complicated  actions, 
sometimes  of  a  dangerous  character,  without  being  aware 
of  it — automatism.  These  automatic  states  may  last  a 
long  time,  several  days  and  weeks.  When  the  patients 
regain  their  normal  consciousness,  they  cannot  remember 
any  events  that  may  have  taken  place  during  the  spell. 
There  is  a  perfect  gap  of  memory  for  the  entire  duration 
of  the  spell. 

The  amnesia  of  the  epileptics  is  of  great  moment 
in  forensic  matters.  If  an  epileptic  has  committed  a 
criminal  act  during  a  psychic  equivalent,  it  is  of  con- 
siderable importance  for  the  medico-legal  expert  to  de- 
monstrate that  the  defendant  has  a  gap  in  his  memory. 
For  this  would  establish  the  fact  that  he  is  subject  to 
psychic  equivalents  and  would  render  him  irresponsible 
during  these  periods. 


GENERAL  PATHOLOGY  (^y 

A  similar  amnesia  and  gaps  of  memory  are  met 
with  in  patients  suffering  from  other  diseases  in  which 
spells  of  loss  of  consciousness  occur,  as  in  hysterical 
patients. 


Chapter  XXXIV. 
SOME    PECULIAR    DISTURBANCES    OF   MEMORY. 

A  remarkable  impairment  of  memory  occurs  after 
attempts  at  suicide  through  hanging.  It  is  evident  from 
the  foregoing  chapter  that  the  patient  is  unable  to  re- 
member anything  that  has  taken  place  during  the  time 
of  unconsciousness.  But  what  is  rather  strange  is  that 
he  cannot  remember  what  has  immediately  preceded 
the  suicidal  attempt.  Thus  he  does  not  know  what  im- 
plement he  has  made  use  of  to  hang  himself.  This  form 
of  amnesia  can  be  produced  experimentally.  When  the 
carotid  arteries  are  compressed,  the  individual  experi- 
mented upon  quickly  loses  consciousness  (p.  5).  When 
the  compression  ceases,  consciousness  returns.  The  in- 
dividual cannot  remember  the  incidents  preceding  the  ex- 
periment. He  does  not  know,  for  instance,  whether  or 
not  he  has  given  his  consent  to  the  experiment.  At  this 
place  it  is  necessary  to  remark  that  the  experiment  re- 
quires great  caution.  The  compression  of  the  arteries 
has  to  be  performed  very  slowly.  Immediately  after 
unconsciousness  has  ensued,  the  compression  of  the  ar- 
teries must  cease,  and  this  very  gradually  too.  With 
this  precaution  the  experiment  is  not  dangerous. 

Another  peculiar  disturbance  of  memory  consists  in 
deception  of  memory.  Even  sane  people  have  some- 
times a  feeling  as  though  they  had  been  before  in  a  given 


6S  PSYCHE 

situation,  although  this  has  never  been  the  case.  This 
feeHng  is  transient.  But  there  are  patients  in  whom 
such  feehngs  are  rather  permanent.  They  maintain, 
without  any  affectation  or  boastfulness,  to  have  known 
or  seen  things  that  are  shown  to  them  for  the  first  time 
in  their  Hfe.  Confounding  of  persons  is  based  on  such 
deceptions  of  memory.  The  patients  beHeve  to  know  a 
person  whom  they  meet  for  the  first  time,  or  to  recognize 
in  him  an  old  acquaintance.  Things  belonging  to  others 
are  appropriated  by  such  patients  and  claimed  as  their 
own,  and  in  this  way  they  may  come  into  conflict  with 
the  Penal  Code  (pp.  89,  255). 


Chapter  XXXV. 
COMPULSORY  IDEAS. 

Certain  ideas  have  been  designated  as  compulsory 
C'Zwangsideen").  The  person  harboring  these  ideas 
is,  somehow  or  other,  under  compulsion  to  have  them 
constantly  in  his  consciousness  and  cannot  rid  himself 
of  them.  Compulsory  ideas  are  met  with  not  only  in 
patients,  but  also  in  persons  who  are  sane  and  even  in- 
telligent and  equal  to  their  vocation  in  life. 

It  has  been  said  every  idea  that  intrudes  upon  the 
consciousness  of  a  person  and  persists  against  his  will  is 
a  compulsory  idea.  This  definition  is  too  narrow;  for 
there  are  ideas  which  are  intruding  upon  the  conscious- 
ness of  a  person  and  persisting  against  his  will  and  yet 
cannot  justly  be  called  compulsory.  A  person  may  com- 
mit a  wrong  and  be  constantly  haunted  by  the  idea  of 
his  improper  act,  and  yet  the  term  compulsory  idea  is 


GENERAL  PATHOLOGY  69 

1 
not  applicable  to  such  an  instance.  We  speak  here  rather 
of  the  voice  of  conscience.  When  one  is  expecting  an 
event  capable  of  causing  him  sorrow  or  joy,  the  idea  of 
it  intrudes  upon  his  mind  and  persists  against  his  will. 
A  student  often  has  to  think  of  the  imminent  examina- 
tion in  the  midst  of  his  pleasures,  and  yet  we  do  not  say 
he  is  suffering  from  a  compulsory  idea. 

To  arrive  at  the  proper  conception  of  compulsory 
or  imperative  ideas,  it  is  advisable  to  consider  a  few  ex- 
amples of  ideas  which  may  unquestionably  be  called 
compulsory.  A  patient  complained  that  the  number  13 
was  always  present  in  his  mind.  He  knows  that  a  certain 
significance  is  attributed  to  this  number,  but  he  does  not 
share  this  superstition.  Another  patient  was  grieved 
about  having  to  think  of  certain  blasphemous  words 
whenever  he  took  a  prayer  book  into  his  hands.  In  spite 
of  his  endeavors  he  does  not  succeed  to  disconnect  in  his 
thoughts  obscene  things  from  holy  ones.  On  the  con- 
trary, when  he  does  not  resist  the  course  of  his  thoughts, 
he  feels  more  relieved.  Again  another  patient  was  an- 
noyed that  whenever  he  beheld  a  woman  he  could  not 
dissociate  from  her  the  idea  of  her  being  pregnant. 

The  common  feature  in  all  these  instances  is  that 
the  patients  are  perfectly  convinced  of  the  insignificance 
and  absurdity  of  the  idea  that  occupies  their  mind.  In 
other  instances,  however,  the  subject  of  the  idea  is  of 
great  importance.  A  woman,  mother  of  one  child,  was 
constantly  haunted  by  the  thought  that  the  child  might 
fall  out  of  the  window  during  her  absence.  In  this  alone 
there  is  nothing  strange  inasmuch  as  any  tender  mother's 
mind  may  very  well  be  invaded  by  such  a  thought.  But 
the  pathological  feature  is  that  she  was  compelled  to 
imagine  the  child  had  fallen  down  and  was  lying  on  the 


70  PSYCHE 

ground  with  crushed  Hmbs.  She  fancied  that  when  she 
would  be  in  the  room  with  the  child  at  the  window,  she 
might  push  it  off  from  the  sill  to  see  whether  the  actual 
scene  of  the  child  falling  down  and  being  crushed  cor- 
responded to  the  horrible  picture  of  her  imagination. 
She  was  positively  afraid  to  be  alone  in  the  room  with 
the  child. 

Another  form  of  compulsory  idea  is  the  tendency 
to  ponder  over  problems  which  do  not  have  the  slightest 
value  C'Grubelsuchf').  The  patients  constantly  analyze 
nonsensical  questions,  for  instance,  why  two  times  two 
are  four  and  no  other  number,  or  why  the  world  has 
been  created  in  six  days  and  not  in  five.  The  patients 
are  aware  of  the  ridiculousness  of  these  problems. 

To  the  compulsory  ideas  belongs  the  habit  of  doubt- 
ing— folic  du  doute.  At  night  before  going  to  bed  the 
patient  shuts  the  gate  of  the  house.  When  he  has  laid 
himself  to  sleep,  he  gets  the  idea  that  he  did  not  close 
the  gate  properly.  It  worries  him  so  long  that  he  feels 
compelled  to  get  up  and  convince  himself  that  the  gate 
is  closed.  When  he  is  in  bed  again,  the  same  idea  begins 
to  disturb  him  anew  and  causes  him  to  get  up.  This  may 
be  repeated  several  times.  Something  similar  occurs  in 
writing  letters,  counting  money,  extinguishing  lights,  and 
so  on.  One  writes  a  few  letters  and  puts  them  in  their 
respective  envelopes.  Thereupon  the  idea  begins  to 
trouble  him  that  he  has  mixed  up  the  letters  and  compels 
him  to  tear  open  the  envelopes.  This  act  he  has  to  repeat 
several  times.  Another  one  cannot  satisfy  himself  that 
he  has  counted  his  money  correctly  and  has  to  count  it 
over  and  over  again. 

Among  the  compulsory  ideas  are  to  be  counted  the 
various  phobias.     Some  patients  suffer  from  the  fear  of 


GENERAL  PATHOLOGY  71 

contact — delire  du  contact.  They  scrupulously  avoid 
touching  many  things  for  fear  of  taking  in  some  germ 
of  disease.  Other  patients  have  casually  read  that  people 
had  become  victims  of  rabies  without  knowing  that  they 
had  been  bitten  by  a  dog.  From  that  moment  the  idea 
worries  them  that  they  also  may  have  been  bitten  by  a 
mad  dog  without  knowing  it.  Some  patients  are  in  con- 
stant fear  of  their  clothes  becoming  dusty  or  of  being 
soiled  in  some  other  way — mysophohia.  Patients  affected 
with  the  so-called  agoraphobia  are  unable  to  pass  a  public 
square  or  a  street,  or  to  approach  a  gathering  of  peo- 
ple (p.  39).  Astraphohia  is  the  exaggerated  fear  of 
thunder  and  lightning.  The  patients  are  seized  with 
apprehensive  excitement  even  at  the  approach  of  thun- 
derstorms and  are  sometimes  so  sensitive  that  they  can 
predict  them  long  before  they  appear,  the  same  as  rheu- 
matic patients  foretell  weather-changes.  Patients  suffer- 
ing from  claustrophobia  are  afraid  to  stay  in  closed 
rooms.  Other  phobias  refer  to  the  activities  of  the  in- 
ternal organs.  Thus  some  patients  are  in  constant  fear 
that  their  heart  may  stop,  or  their  lungs  discontinue  to 
breathe. 

These  are  all  examples  of  real  compulsory  or  im- 
perative ideas.  It  is  true,  they  persist  in  the  conscious- 
ness of  the  patient  against  his  will.  But  this  is  not 
essential.  What  is  more  important  is  that  he  cannot  rid 
himself  of  them  notwithstanding  his  firm  conviction  of 
their  absurdity  and  insignificance.  A  patient  laboring 
under  agoraphobia  knows  very  well  that  no  disaster  is 
likely  to  befall  him  in  crossing  a  street. 

To  obtain  a  satisfactory  definition  of  compulsory 
idea  the  question  must  be  answered  what  enables  a 
healthy  person  to  retain  certain  ideas  and  to  abandon 


72  PSYCHE 

others  forthwith,  for  instance,  what  makes  him  give  up 
thinking  why  two  times  two  are  four  and  no  other 
number.  He  succeeds  herein  first  by  the  conviction  of 
the  utter  insignificance  of  the  problem.  But  since  pa- 
tients also  have  this  conviction,  some  other  factor  must 
play  an  important  part.  This  factor  is  found  when 
intelligent  patients  are  questioned.  They  report  that 
they  are  well  aware  of  the  absolute  insignificance  and 
even  of  the  ridiculousness  of  the  idea  they  constantly 
have  to  keep  in  mind,  but  that  nevertheless  they  cannot 
get  rid  of  a  certain  feeling  as  though  the  thing  is  im- 
portant after  all.  To  this  feeling  they  have  to  yield 
contrary  to  their  conviction.  Now,  in  the  healthy  per- 
son with  the  knowledge  that  a  problem  is  insignificant 
and  void  is  connected  a  corresponding  feeling  that  the 
problem  is  to  no  purpose.  It  is  a  peculiar  affective  tone. 
It  is  owing  to  this  feeling  that  he  is  not  compelled  to 
think  over  the  useless  problem  and  is  able  to  dissociate 
it  from  the  train  of  his  thoughts.  In  the  diseased  indi- 
vidual, however,  the  conviction  of  the  insignificance  of  a 
thing  either  lacks  the  normal  affective  tone  or  is  accom- 
panied by  an  abnormal  feeling.  All  these  preceding  con- 
siderations lead  us  to  the  following  definition  of  com- 
pulsory idea.  //  with  a  certain  idea  an  abnormal  affec- 
tive tone  is  associated,  and,  due  to  this  morbid  feeling, 
the  idea  is  retained  in  consciousness  against  the  will  not- 
withstanding complete  conviction  of  the  insignificance 
of  the  subject,  this  idea  is  a  compulsory,  imperative  idea. 
Compulsory  ideas  are  met  with  during  convalescence 
from  psychoses.  But  also  persons  who  have  never  had 
a  psychosis  may  be  subject  to  them.  As  a  rule,  those 
affected  are  people  with  a  family  history  of  insanity. 


GENERAL  PATHOLOGY  73 

Fatigue  may  also  be  regarded  as  an  etiological  factor,  as 
in  psychasthenics. 

Some  patients  become  incapacitated  for  useful  work 
through  their  compulsory  ideas.  Other  patients  have 
even  to  be  committed  to  an  insane  asylum  on  account  of 
them.  For  such  ideas  sometimes  increase  to  impulses, 
and  the  latter  may  lead  to  compulsory  actions  which  ren- 
der the  patient  dangerous  to  himself  and  his  neighbors 
(Chapter  42,  p.  86). 


Chapter  XXXVI. 

MORBID  ALTERATION  OF  THE  ACTIVITY  OF  THE 
UNDERSTANDING. 

In  abnormal  conditions  of  the  memory,  which  fur- 
nishes the  elements  for  the  activity  of  the  understand- 
ing (p.  21),  the  latter  is  also  morbidly  affected.  As 
with  memory  so  also  with  understanding  increased  and 
diminished  capacity  may  be  distinguished. 

When  the  ideational  process  is  facilitated,  there  is 
more  ready  material  for  the  activity  of  the  understand- 
ing. In  maniacal  excitement  of  moderate  degree,  there- 
fore, the  capacity  of  understanding  is  enhanced  (Ch. 
8,  pp.  19-20;  pp.  36,  61,  62).  It  is  generally  known  that 
moderate  excitement  sometimes  improves  the  intellec- 
tual faculties.  Some  people  seek  a  little  excitement  when 
they  have  to  perform  a  difficult  mental  task;  they  drink 
some  wine  or  strong  coffee  or  smoke  a  little.  These 
stimulants  produce  a  slight  excitement  which  renders 
thinking  more  easy  by  facilitating  the  association.  Pa- 
tients in  maniacal  excitement  are  quicker  at  repartee, 
more   wittv,    and    draw    conclusions    from   their    obser- 


74  PSYCHE 

vations  with  more  ease  than  usually.  But  when  the 
maniacal  excitement  is  great,  the  understanding  is  im- 
paired, owing  to  '^flight  of  ideas"   (pp.  36,  42). 

Sometimes  increased  capacity  of  understanding  is 
merely  apparent,  as  in  the  hypermnesia  of  the  idiots 
(pp.  62-63).  These  patients  may  create  the  impression 
of  being  highly  intelligent  simply  by  virtue  of  their  faith- 
ful memory  which  enables  them  to  learn  quickly  and  to 
appropriate  ideas  and  judgments  of  others  more  readily 
than  is  normally  the  case. 

Far  more  frequent  than  the  increased  is  the  dimin- 
ished capacity  of  understanding.  It  is  observed  in  the 
transitory  retardation  of  the  ideational  process  in  melan- 
cholia. The  understanding  of  melancholic  patients  is 
secondarily  impaired,  being  influenced  by  the  difficulty 
of  association.  It  is  laborious  for  the  melancholies  to 
combine  sensations  and  memory  images.  When  the 
melancholic  depression  has  ceased,  the  understanding 
gradually  improves  (pp.  19-20,  35,  64). 

In  primary  insanity,  paranoia,  an  impairment  of 
understanding,  occurs  which  may  be  called  ''want  of 
critique."  The  patients  are  unable  to  gauge,  so  to  say, 
their  observations,  to  pay  attention  to  the  quantitative 
elements  of  the  understanding.  A  few  examples  will 
suffice.  A  patient  maintained  that,  owing  to  his  intimate 
relations  to  the  Bavarian  Royal  House,  he  had  excellent 
prospects  for  the  future.  Called  upon  to  prove  his  asser- 
tion, he  argued  as  follows :  His  foot  stool  had  the  colors 
blue  and  white;  the  colors  of  the  Bavarian  Royal  house 
were  also  blue  and  white,  therefore  he  belonged  to  the 
Royal  house.  The  facts  are  unquestionably  correct,  but 
the  conclusion  drawn  from  them  is  anything  but  rational. 
Another  patient  said  that  he  would  become  governor  of 


GENERAL  PATHOLOGY  75 

the  state,  and  the  only  reason  he  gave  for  this  statement 
was  that  his  birth  fell  on  a  certain  date.  This  "want  of 
critique"  is  never  missing  in  paranoiacs.  They  interpret 
the  most  casual  circumstances  to  their  advantage  or  dis- 
advantage. This  impairment  of  understanding  may 
be  transitory.  Should  the  acute  mental  malady  pass 
away  or  come  to  a  standstill,  the  power  of  understand- 
ing may  become  normal  again. 

In  some  cases  where  the  capacity  of  understand- 
ing appears  to  be  reduced  we  are  dealing  merely  with 
delusions.  It  is  necessary  to  bear  this  point  in  mind 
since  real  impairment  of  understanding  involves  more 
or  less  an  unfavorable  prognosis.  When  a  patient 
utters  an  obvious  absurdity,  for  instance,  when  a  rich 
patient  complains  about  dire  poverty,  we  must  not  as- 
sume at  once  that  his  power  of  understanding  has  been 
really  reduced.  Melancholic  patients  often  express  sim- 
ilar nonsensical  assertions  which  are  nothing  else  but  de- 
lusions, and  do  not  signify  an  impairment  of  under- 
standing. That  in  such  instances  the  capacity  of  under- 
standing has  not  suffered,  is  proved  by  the  fact  that 
the  patients  are  again  in  full  possession  of  their  intelli- 
gence when  the  delusions  cease  with  the  discontinuance 
of  their  own  causative  factors,  morbid  mood  and  hallu- 
cinations (Ch.  25,  pp.  53-54). 

The  capacity  of  understanding  is  permanently  low- 
ered in  idiocy,  in  secondary  dementia,  and  in  general 
paresis.  The  greatest  diminution  of  the  intellectual 
faculties  is  met  with  in  these  conditions.  Persons  mag- 
nificently gifted  intellectually  may  become  so  stupid  that 
they  do  not  recognize  their  nearest  relatives,  are  unable 
to  tell  their  name  or  their  age,  and  so  on. 

In  forensic  respect  laymen  ascribe  too  much  impor- 


j(>  PSYCHE 

tance  to  the  faculty  of  understanding.  They  consider  a 
crime  punishable,  if  the  criminal  has  acted  consciously 
and  intelligently.  Now,  insane  criminals  report  that  in 
committing  a  wrong  act  they  were  in  full  possession  of 
their  consciousness  and  understood  very  well  the  criminal 
bearing  of  their  action.  Yet  they  performed  it,  induced 
by  a  delusion,  for  instance,  by  the  delusion  of  being  per- 
secuted. Society  ought  not  to  inflict  punishment  in  such 
cases.  For  it  ought  not  to  inquire  whether  or  not  a 
criminal  has  acted  intelligently,  but  whether  he  has  acted 
in  a  state  of  unconsciousness  or  such  other  derangement 
of  the  mental  faculties  in  which  freedom  of  the  will 
could  be  excluded. 


SECTION  III. 

PATHOLOGY   OF    THE  ACTIVITY    OF 
THE   WILL 


Chapter  XXXVIL 

INCREASE  AND  DECREASE  OF  THE  FREQUENCY 
OF  VOLITIONAL  MANIFESTATIONS. 

The  activity  of  the  will  has  a  positive  and  a  nega- 
tive side.  For  will  is  the  capability  of  reenforcing 
motor  images  to  such  an  extent  that  movements  ensue, 
and  on  the  other  hand  of  weakening  motor  images  so 
that  movements  for  which  an  incentive  is  present  are 
suppressed. 

Morbid  alteration  of  the  activity  of  the  will  is  a 
very  frequent,  diagnostically  important  symptom.  It  is 
met  with  in  mild  and  in  grave  forms  of  mental  disease. 
A  common  symptom  of  psychasthenia  is  the  want  of 
choice  or  initiative,  aboulia,  paralysis  of  the  will.  The 
patients  are  unable  to  accomplish  the  plainest  actions, 
they  vacillate  and  hesitate  and  cannot  come  to  a  decision. 

In  graver  mental  diseases  disturbance  of  the  activity 
of  the  will  becomes  most  conspicuous  through  unusual 
frequency  of  the  volitional  acts.  It  may  be  abnormally 
increased  or  abnormally  diminished,  the  patient  being 
compelled  to  act  according  to  his  condition.  While  the 
sane  person  has  the  choice  of  performing  few  volitional 
acts  or  many,  the  patient  in  whom  the  frequency  of  voli- 
tional manifestations  is  abnormally  increased  cannot  re- 


78  PSYCHE 

duce  it,  and  conversely,  when  it  is  abnormally  diminished, 
the  patient  is  unable  to  carry  out  many  movements. 

Increased  volitional  activity  is  a  salient  symptom  of 
maniacal  excitement.  The  movements  of  the  patients 
are  rapid.  They  speak  quickly.  In  conversation  one 
hardly  succeeds  to  make  them  stick  to  one  subject.  They 
are  extremely  restless.  They  cannot  sit  quietly  for  a 
moment,  now  they  do  this,  now  that.  When  they  are  iso- 
lated, they  tug  at  their  clothes,  tear  and  tatter  them,  pluck 
and  twist  their  hair,  and  perform  all  kinds  of  manipula- 
tions. The  patients  cannot  behave  differently;  we  may 
say  they  are  under  an  irresistible  impulse  for  movement. 

The  patient  with  diminished  frequency  of  volitional 
manifestations,  hypoboulia,  sits  quietly  and  hardly  stirs. 
In  extreme  cases  the  patients  are  unable  to  take  nourish- 
ment or  to  swallow  food  introduced  into  their  mouths, 
and  even  normal  reflex  movements  may  remain  in  abey- 
ance. Such  a  reduction  of  the  volitional  processes  is 
seen  in  stupor  (Ch.  72,  p.  159).  A  more  moderate  sup- 
pression of  the  activity  of  the  will  belongs  to  the  symp- 
toms of  melancholia.  The  patients  remain  sitting  on 
one  spot  for  hours.  They  make  no  effort  to  go  to  bed 
at  night,  to  undress  themselves,  or  to  get  up  in  the  morn- 
ing. They  stay  in  bed  for  days  and  weeks,  not  leaving 
it  even  after  having  soiled  it.  They  are  extremely  re- 
ticent. A  conversation  can  be  carried  on  with  them  only 
with  great  difficulty,  at  most  they  answer  yes  or  no  to 
some  questions.  An  exact  description  of  what  is  ailing 
them  cannot  be  obtained  from  them.  They  speak  with  a 
low  voice  and  slowly,  they  walk  hesitatingly  and  halt 
frequently.  This  diminution  of  the  activity  of  the  will 
is  transitory,  ceasing  with  the  disapperance  of  the  melan- 
cholic depression. 


GENERAL  PATHOLOGY  79 

The  frequency  of  the  volitional  manifestations  is 
permanently  reduced  in  some  cases  of  secondary  de- 
mentia. Some  demented  patients  are  so  apathetic  that 
they  remain  motionless  on  one  spot  for  so  long  a  time 
that  their  extremities  become  swollen.  They  may  be 
unable  to  eat  and  drink,  to  dress  and  undress  themselves, 
etc.  This  lethargic  condition  stays  with  such  patients 
throughout  their  lives. 


Chapter  XXXVIIL 
TICS,  STEREOTYPY. 

Among  the  disturbances  of  volition  are  to  be  in- 
cluded certain  abnormal  motor  phenomena  not  infre- 
quently observed  in  mental  diseases. 

The  tics  are  curious  gestures  and  motions,  such  as 
twitching  of  muscle  groups,  grimacing,  licking  the  palate, 
clucking  with  the  tongue,  snuffling,  throwing  head  and 
limbs  in  various  positions,  etc.  These  sudden  incoordin- 
ate movements  are  sometimes  responses  to  external 
stimuli.  Usually,  however,  they  represent  the  rigid  re- 
mains of  habitual  actions  and  movements,  ensuing  auto- 
matically or  not  controlled  by  the  will  (Kraepelin). 

Similar  to  the  tics  are  the  stereotyped  movements. 
Normally  every  impulse  ceases  when  its  aim  has  been 
reached.  Another  impulse  enters  the  field  of  conscious- 
ness only  to  be  supplanted,  after  attainment  of  its  end, 
by  a  new  impulse.  Thus  complex  actions  are  accom- 
plished by  one  impulse  replacing  its  predecessor  when 
the  latter 's  part  of  the  action  has  been  achieved.  This 
normal  harmony  of  the  common  impulses  may  be  dis- 
turbed.   Stereotypy  is  the  morbid  persistence  of  a  motor 


8o  PSYCHE 

impulse  causing  the  patient  to  persevere  in  certain  atti- 
tudes for  a  long  time  or  to  repeat  certain  movements 
over  and  over  again.  Stereotypy  of  attitude  is  desig- 
nated as  akinetic,  that  of  movement  as  kinetic. 

Patients  showing  akinetic  stereotypy  keep  up  cer- 
tain postures  of  body  and  Hmbs  for  any  length  of  time, 
even  though  they  may  be  extremely  uncomfortable. 
Some  patients  kneel  for  hours  and  days  on  a  hard  floor, 
others  lie  in  bed  with  extended  head  and  curled  limbs, 
the  body  being  so  rigid  that  it  can  be  lifted  by  one  limb. 
In  stereotyped  attitudes  of  the  facial  muscles  there  is  a 
continued  distortion  of  the  features.  The  face  assumes 
a  mask-like  appearance,  the  eyes  are  staring  without  the 
slightest  movement  of  the  lids,  or  else  the  lids  are  tightly 
closed,  the  lips  are  protruded  forming  a  snout  (''snouting 
cramp"),  etc. 

In  kinetic  stereotypy  the  patients  perform  certain 
acts  innumerable  times,  such  as  rocking,  hopping,  jump- 
ing, rapping  rhythmically,  pacing  up  and  down  the  room 
in  the  same  line,  etc. 

Frequently  the  patients  exhibit  with  their  stereo- 
typed movements  a  certain  affectation — inannerism. 
They  walk  in  a  solemn  attitude,  describing  circles  or 
other  lines.  Mannerism  is  manifested  especially  in 
stereotypy  of  speech.  The  patients  use  stilted  language 
and  speak  in  an  affected  manner,  e.  g.,  lisp,  speak  in  a 
falsetto  voice,  weep  after  a  certain  melody,  etc. 

Verbigeration  is  the  c(^tant  repetition  of  senseless 
syllables,  words,  and  phrases.  It  occurs  not  only  in  oral, 
but  also  in  written  language.  In  the  writing  of  the  pa- 
tient a  page  may  be  found  containing  nothing  else  but 
the  same  word  or  phrase  written  over  and  over  again. 


GENERAL  PATHOLOGY  8i 

Chapter  XXXIX. 
INTERFERENCE,  DERAILMENT  OF  THE  WILL. 

In  stereotypy  many  actions  never  lead  to  a  goal 
because  of  the  persistence  of  one  impulse  which  pre- 
cludes other  impulses  pertaining  to  the  actions.  There 
is,  however,  another  disturbance  of  volition  in  which  the 
goal  is  finally  reached,  but  by  a  long  roundabout  way. 
Fortuitous  impulses  arise,  interfering  with  those  on 
which  the  intended  act  depends,  and  delay  its  accom- 
plishment. The  latter  comes  about  after  the  interpolation 
of  superfluous  operations  which  appear  as  embellish- 
ments of  the  intended  act  (Kraepelin).  The  patient  puts 
his  garment  on  inside  out,  walks  with  short  steps,  swings 
the  chair  in  the  air  before  sitting  down,  crosses  his  arms 
when  shaking  hands,  makes  various  manipulations  with 
the  spoon  in  eating,  drinks  water  with  little  sips,  etc. 

From  this  interference  of  fortuitous  impulses  with 
the  main  impulses  there  is  a  gradual  transition  to  that 
disturbance  of  the  will  in  which  the  goal  of  the  intended 
act  is  not  reached  at  all  because  the  incidental  impulses 
divert  the  patient  in  a  different  direction — derailment  of 
the  ivill.  He  stands  up  to  walk  into  another  room,  but 
trips  along,  dances  about,  and  sits  down  again.  He 
starts  to  drink  a  glass  of  water,  but  turns  it  upside  down 
and  puts  it  on  the  table.  His  countenance  assumes  an 
attitude  of  weeping  and  tears  fill  his  eyes,  and  then  his 
face  becomes  suffused  wi#|fsmiles — paramimia. 


82  PSYCHE 

Chapter  XL. 
HYPERSUQQESTIBILITY,  NEGATIVISM. 

It  may  be  regarded  as  a  disturbance  of  the  negative 
side  of  the  will  (p.  "jy)  when  actions  follow  too  readily 
upon  inadequate  stimuli.  Such  patients  lack  the  will 
power  to  disregard  incentives  too  trivial  to  call  forth 
responses  in  normal  persons.  They  are  possessed  by  a 
hyper  suggestibility  which  causes  them  to  respond  to  any 
accidental  influence.  The  perception  of  a  certain  move- 
ment is  for  them  a  sufficient  stimulus  to  make  this  move- 
ment. They  wrinkle  the  forehead,  whistle,  jump,  when 
they  see  others  do  so — automatism  of  imitation,  echo- 
praxia.  Sometimes  they  repeat  what  one  says  in  their 
presence,  or  interpolate  frequently  in  their  talk  irrelevant 
words  and  phrases  which  they  have  accidentally  heard — 
echolalia.  Hypersuggestibility  is  a  characteristic  feature 
of  hypnotism.  A  command  from  the  hypnotizer  is  suffi- 
cient incitement  for  his  subject  to  perform  all  kinds  of 
senseless  actions — automatism  of  command. 

Hypersuggestibility  is  observed  in  various  mental 
disorders.  In  catalepsy  the  will  power  is  so  weak  that 
the  limbs  of  the  patient  can  be  put  in  any  position  and, 
in  spite  of  great  discomfort,  remain  in  that  position  un- 
til one  changes  it,  or  until  they  drop  owing  to  complete 
exhaustion  of  their  muscles.  The  peculiar  rigidity  of 
the  muscles  in  these  conditions  is  called  fiexihilitas  cerea. 

The  disturbance  of  volition,  called  negativism,  and 
in  its  manifestations  almost  the  contrary  of  hypersug- 
gestibility, consists  in  an  exaggerated  inaccessibility  to 
any  external  influence.  The  patient  ofl^ers  resistance  to 
the  requirements  of  environment  and  circumstances,  re- 
fuses to  fulfill  the  most  reasonable  demands,  and  even 


GENERAL  PATHOLOGY  83 

does  just  the  opposite  of  what  he  is  requested  to  do.  He 
does  not  respond  to  a  greeting  and  recoils  when  ap- 
proached even  in  the  most  friendly  way.  He  withdraws 
his  arm  when  the  hand  is  offered  him  in  greeting,  presses 
his  teeth  together  when  asked  to  show  his  tongue.  To- 
wards all  questions  he  remains  mute — mutism,  or  brings 
forward  entirely  irrelevant  utterances — paralogia,  ''Vor- 
beiredcnf  He  does  not  heed  even  his  physical  needs, 
refusing  to  eat  or  drink,  or  to  evacuate  bladder  and 
rectum,  especially  when  exhorted  to  do  so. 


Chapter  XLL 
MORBID  ALTERATION   OF  THE   ENERGY. 

Energy  is  displayed  in  two  ways,  in  the  application 
of  great  muscular  power  while  acting,  and  in  persistent 
and  purposeful  action.  For  the  sake  of  brevity  the  first 
form  of  energy  may  be  called  energy  of  force,  the  second 
energy  of  persistence.  Both  forms  of  energy  may  show 
morbid  alteration,  most  frequently,  however,  only  one  is 
changed.  Some  patients  manifest  an  increase  of  one 
form  and  a  decrease  of  the  other. 

Increase  of  the  energy  of  force  is  met  with  in 
maniacal  excitement.  The  maniacs  speak  loudly,  as 
though  their  listeners  were  hard  of  hearing.  When  their 
attention  is  called  to  their  loud  speech,  they  lower  their 
voice  for  a  while,  but  soon  resume  their  former  powerful 
tone.  Their  step  is  firm,  their  grasp  forceful.  In  short, 
everywhere  they  apply  considerably  more  power  and 
strength  than  is  required  for  the  attainment  of  the  pur- 
pose.     Their    performances    are    sometimes    incredible. 


S4  PSYCHE 

They  bend  iron  bars,  rend  strait- jackets,  break  massive 
furniture.  Nothing  seems  to  be  too  firm  for  them. 
Some  have  maintained  that  the  muscular  power  of 
maniacs  is  actually  increased.  But  this  is  not  the  case. 
They  merely  apply  that  amount  of  force  which  the  sane 
person  would  use  only  in  the  highest  distress  and  danger. 
The  maniacs  perform  such  astonishing  deeds  because 
they  are  inconsiderate  of  their  health.  By  instinct  the 
sane  person  avoids  applying  more  power  than^  is  just 
necessary  to  accomplish  a  certain  end.  He  thus  reserves 
his  strength  and  wards  off  the  harm  which  the  abuse  of 
muscular  power  entails.  Maniacs  lack  this  fine  instinct 
and  go,  therefore,  far  beyond  the  required  measure  of 
power  in  using  their  muscles. 

Paretics  in  maniacal  excitement  behave  in  a  similar 
manner,  but  do  not  possess  the  same  dexterity  and  elas- 
ticity as  other  maniacs.  Their  movements  do  not  lack 
coarse  muscular  power,  but  fail  to  show  skil fulness  and 
finer  coordination. 

The  abuse  of  muscular  power  shows  itself  also  in 
unusually  long  duration  of  an  action.  In  this  respect 
astonishing  examples  of  great  energy  are  observed  in 
maniacs.  They  walk  up  and  down  the  room  for  days 
and  weeks,  they  talk  incessantly  in  a  very  loud  tone  of 
voice  for  weeks  and  even  months. 

Diminution  of  the  energy  of  force  is  met  with  in 
melancholic  patients.  Their  grasp  is  weak,  they  speak 
with  a  low,  feeble  voice,  they  walk  slowly  and  with  in- 
firm step.  In  an  emotional  attack  of  fear,  however,  they 
may  display  great  muscular  strength  (pp.  33,  34).  Mod- 
erate reduction  of  the  energy  of  force  is  also  seen  in  de- 
mented patients.  The  maximum  lowering  of  this  form 
of   energy  is  observed  in  stupor.     All  that  stuporous 


GENERAL  PATHOLOGY  85 

patients  can  still  accomplish  by  muscular  power  is  to 
stand  quietly  as  if  rooted  to  the  spot,  motionless  for 
hours. 

As  to  purposeful  and  persistent  action,  the  energy 
is  increased  in  paranoiacs.  With  greatest  consideration 
and  perseverance  they  pursue  a  certain  design.  Induced 
by  delusions,  for  instance  by  the  delusion  that  somebody 
wants  to  poison  them,  they  steadfastly  decline  to  take 
nourishment.  They  may  be  so  consistent  in  their  refusal 
of  food  that  they  would  actually  die  of  starvation  if 
artificial  feeding  were  not  resorted  to.  Paranoiacs  influ- 
enced by  delusions  perform  actions  which  sane  persons 
would  never  be  capable  of.  In  this  category  belong  hor- 
rible self-mutilations  or  self -crucifixion.  Great  persistence 
is  shown  by  paranoiacs  in  carrying  out  plans  of  flights. 
With  finesse  they  manage  to  procure  a  piece  of  iron, 
make  a  sort  of  file  out  of  it,  and  saw  through  the  window 
bars.  Day  after  day  they  file  a  little  at  a  bar  until  it 
finally  yields.  Increased  energy  is  also  seen  in  the  plans 
which  patients  contrive  against  the  lives  of  those  who 
restrict  their  freedom,  or  in  the  manner  in  which  they 
accomplish  self-destruction.  If  all  instruments  to  com- 
mit suicide  have  been  removed,  they  kill  themselves  by 
running  head  forward  against  a  wall,  a  feat  for  which 
incredible  energy  is  required.  Some  patients  also  show 
great  energy  in  enduring  hardships,  as  extreme  cold  or 
heat. 

Increased  energy  of  persistence  similar  to  that  of 
paranoiacs  is  sometimes  observed  in  idiots. 

Enhancement  of  the  energy  of  persistence  is  much 
more  frequent  in  psychoses  than  increased  energy  of 
force.  The  latter  sometimes  exists  without  the  former. 
This  is  especially  the  case  in  maniacal  excitement.     The 


86  PSYCHE 

stronger  the  agitation  of  the  patient,  the  less  is  he  able 
to  pursue  a  purpose.  Owing  to  "flight  of  ideas"  the 
maniac  is  unable  to  carry  out  an  intention  completely, 
being  easily  diverted  in  another  direction.  To  this  qual- 
ity is  due  the  " tractahllity"  of  the  maniacs.  By  taking 
advantage  of  it  a  raging  maniac  may  be  easily  subdued, 
while  otherwise  the  help  of  several  attendants  would  be 
required  to  manage  him.  Physicians  would  do  well  to 
bear  this  point  in  mind  in  the  handling  of  maniacal 
patients. 

The  energy  of  persistence  is  diminished  in  secondary 
dementia.  The  patients  cannot  accomplish  anything  they 
desire,,  are  unable  to  evade  a  danger  when  brought  face 
to  face  with  it. 

In  patients  mentally  deficient  since  birth  or  early 
childhood  increase  as  well  as  decrease  of  the  energy  of 
persistence  is  met  with.  The  plans  of  idiots  vary  from 
day  to  day,  a  slight  allurement  suffices  to  divert  them 
from  their  intention.  It  has  been  mentioned  above  that 
at  times  they  may  resemble  paranoiacs  in  exhibiting  per- 
severance. 

Chapter  XLII. 

COMPULSORY   ACTIONS. 

Compulsory  or  imperative  actions  originate  from 
compulsory  or  imperative  ideas  (Ch.  35,  p.  68)  which, 
increasing  considerably  in  intensity,  are  converted  into 
imperative  impulses.  For  instance,  a  patient  sees  a  razor 
and  the  idea  of  cutting  his  throat  with  it  begins  to  tor- 
ment him.  This  is  an  imperative  idea.  Now  there  may 
supervene  the  strong  desire  to  grasp  the  razor  and  inflict 
the  injury.     This  is  an  imperative  impulse.     If  the  pa- 


GENERAL  PATHOLOGY  ^7 

tient  accomplishes  his  morbid  desire,  he  performs  a  com- 
pulsory action. 

Patients  suffering  from  compulsory  ideas  feel  that 
they  would  be  unable  to  resist  executing  those  acts  to 
which  they  are  instigated  by  the  ideas.  When,  therefore, 
they  are  laboring  under  a  compulsory  idea  pernicious  to 
themselves  or  to  others,  they  hide  every  dangerous  in- 
strument and  avoid  every  occasion  that  would  render 
possible  the  execution  of  the  imperative  action. 

Compulsory  ideas  and  actions  play  an  important 
part  in  forensic  matters,  because  they  frequently  include 
dangers  not  only  to  the  patients,  but  also  to  others.  To 
be  exonerated  from  a  penal  act  a  malingerer  may  allege 
that  he  has  been  under  the  influence  of  a  compulsory 
idea  while  committing  the  act.  But  such  deception  can 
usually  be  detected  without  mucli  difliculty.  For  the 
actions  of  malingerers  turn  out  almost  always  to  their 
own  advantage,  while  true  compulsory  actions  are  usually 
to  no  purpose.  When  a  mother  having  killed  her  child 
maintains  to  have  been  under  the  influence  of  a  compul- 
sory idea,  there  may  be  the  possibility  of  her  seeking 
gain,  as  an  inheritance,  by  the  death  of  the  child.  But 
closer  investigation  will  make  the  matter  clear.  The 
medical  expert,  in  order  to  impress  the  court  and  obtain 
recognition  for  his  testimony,  must  demonstrate  how 
compulsory  actions  originate  and  how  they  are  executed. 
A  mother  being  haunted  by  an  idea  detrimental  to  her 
child  reveals  it  to  others.  She  implores  them  not  to  leave 
her  alone  with  the  child  lest  she  do  it  harm.  If  an  utter- 
ance of  the  mother  to  this  eft'ect  has  been  established, 
the  judge  will  become  convinced  that  he  is  dealing  with 
a  true  imperative  action  and  will  not  deein  the  defendant 
fully  responsible. 


88  PSYCHE 

Chapter  XLIII. 
MORBID    IMPULSES. 

The  natural  impulses  (Ch.  ii,  p.  26)  may  be  mor- 
bidly increased  or  decreased.  Thus  maniacs  show  some- 
times increased  sexual  desire  or  ravenous  appetite.  Mor- 
bid decrease  of  a  natural  impulse  expresses  itself  in  a 
most  striking  manner  through  refusal  of  food,  the  patient 
acting  against  the  instinct  of  self-preservation  which  is 
the  strongest  of  all  natural  impulses. 

Some  writers  have  advanced  the  opinion  that  there 
is  an  impulse  for  murder — phonomania'^ ,  or  for  theft — 
kleptomania,  etc.,  in  individuals  otherwise  entirely  nor- 
mal. But  this  view  is  erroneous.  For  whenever  indi- 
viduals display  remarkable  tendencies  to  theft  or  murder 


*  There  is,  as  far  as  the  writer  has  been  able  to  ascertain,  no 
medico-legal  term  for  "impulse  for  murder,"  derived  from  purely 
Greek  roots  in  a  manner  corresponding  exactly  with  the  Greek 
designations  of  other  morbid  propensities,  such  as  morbid  pro- 
pensity for  theft,  kleptomania;  for  incendiarism,  pyromania;  morbid 
sexual  desire  (in  women),  nymphomayiia,  etc.  These  derivations 
furnish  directly  short,  convenient  terms  denoting  the  person  affected 
with  those  propensities,  as  kleptomaniac,  one  afflicted  with  the  pro- 
pensity for  theft,  etc.  Homicidal  mania,  as  a  medico-legal  term, 
with  its  half  Latin,  half  Greek  basis,  sounds  rather  barbaric  to  a 
philologically  trained  ear,  and  is  inconvenient  because,  unlike  the 
terms  for  other  morbid  propensities,  it  consists  of  two  words.  The 
writer  has,  therefore,  coined  the  word  phonomania,  from  the  Greek 
6  povog,  the  murder,  homicide.  This  gives  at  once  the  convenient 
expression  phonomaniac,  one  bent  on  murder. 

No  less  an  authority  on  medical  terminology  derived  from 
the  Greek  than  Dr.  Achilles  Rose  has  approved  of  the  coinage  of  the 
word,  and  has  refuted  the  writer's  own  objection  that  phonomania 
(<l>ovofiavta)  written  with  Latin  characters,  may  also  mean  "mania 
for  voice"  {^Mvofiafia,  from  r)  (puivt),  the  voice),  with  the  remark 
that  "a  confounding  with  (piovof-tatia  is  excluded  because  something 
like  this  does  not  exist." 


GENERAL  PATHOLOGY  89 

or  other  outrages,  we  can,  on  closer  investigation,  make 
out  delusions  underlying  such  impulses.  An  impulse  to 
steal,  for  instance,  is  observed  in  paretics;  they  regard 
everything  as  their  own  and  try  to  appropriate  it  (p.  255 ). 
The  assumption  of  isolated  impulses  is  to  be  emphatic- 
ally rejected.  Otherwise  the  old  doctrine  of  monomanias, 
fortunately  overthrown  and  abandoned,  would  be  re- 
established. 

Perversities  of  the  natural  impulses  are  quite  fre- 
quent. Sexual  perversities  are  the  most  common  and 
best  known.  Other  perversities  are  less  known.  Patients 
lacking  the  feeling  of  disgust  may  satisfy  their  alimen- 
tive  impulse  in  a  perverse  manner  (Ch.  19,  p.  38). 


SECTION  IV. 
PATHOLOGY   OF  CONSCIOUSNESS. 


Chapter  XLIV. 

DISTURBANCE    OF    SLEEP,    SOMNAMBULISM, 
HYPNOTISM. 

Sleep  occurs  periodically  and  is  characterized  by 
great  reduction  of  consciousness.  Normally  falling 
asleep  and  awaking  require  only  a  comparatively  short 
time,  and  after  awaking  full  consciousness  returns  read- 
ily and  quickly.  These  features  of  sleep  may  be  altered 
in  pathological  conditions.  There  are  patients  who  gain 
their  sleep  slowly  and  with  difficulty.  Other  patients, 
on  the  contrary,  make  all  efforts  to  remain  awake  and 
yet  cannot  help  falling  asleep  even  while  standing  or 
walking  or  on  horseback.  Consciousness  is  reduced  in 
some  patients  much  less  than  is  normally  the  case,  and 
after  awaking  these  patients  do  not  regain  full  conscious- 
ness for  a  long  time.  In  this  semiconscious  state  they 
perform  complicated  actions — automatism.  Cases  are 
reported  where  coachmen  have  arisen  from  bed  in  the 
dead  of  night,  have  led  the  horses  out  of  the  stable,  have 
harnessed  them,  and  have  driven  to  distant  places,  all  this 
in  a  semiconscious  state.  Such  conditions  occur  in  indi- 
viduals who  are  toiling  all  day  long. 

A  sort  of  half-sleep  is  the  so-called  somnambulism, 


GENERAL  PATHOLOGY  91 

sleep-walking.  At  night  the  patients  arise  in  their  sleep 
and,  without  regaining  full  consciousness,  accomplish 
acts  which  are  very  remarkable.  They  may  move  about 
unfalteringly  at  a  giddy  height  on  a  narrow  board.  Lay- 
men see  in  such  accomplishments  something  mysterious. 
But  there  is  no  mystery  therein.  The  sleep-walkers  can 
accomplish  such  feats  because  they  are  not  aware  of 
their  danger  and  are,  therefore,  not  seized  with  dizziness 
as  would  a  waking  person  under  similar  circumstances. 
Indeed,  there  is  nothing  out  of  the  ordinary  in  walking 
over  a  narrow  board  from  one  roof  of  a  house  to  that 
of  another.  No  broader  path  is  necessary  for  a  similar 
walk  on  the  ground.  The  dizziness  produced  by  the 
great  height  makes  the  passage  over  the  narrow  board 
well-nigh  impossible  to  a  person  awake.  When  the  sleep- 
walker is  awakened,  he  is  put  into  a  critical  position. 
For  he  becomes  conscious  of  his  extraordinary  and  pre- 
carious condition  and  is,  therefore,  liable  to  meet  with  a 
fatal  accident. 

Related  to  somnambulism  is  hypnotism,  which  rep- 
resents a  sleep  produced  by  suggestion,  either  by  the 
suggestion  of  others  or  by  autosuggestion.  Its  most  re- 
markable feature  is  the  hypersuggestibility  of  the  hypno- 
tized person,  enabling  the  hypnotizer  to  keep  up  a  spiri- 
tual communication  with  his  subject.  Complicated  acts 
may  be  performed  by  the  hypnotized  person  in  this  state 
of  unconsciousness  at  the  command  of  the  hypnotizer — 
automatism  of  command. 


92  PSYCHE     . 

Chapter  XLV. 

DOUBLE  CONSCIOUSNESS,  STATES  OF  CLOUDED 
CONSCIOUSNESS  IN  EPILEPSY  AND  HYSTERIA. 

The  existence  of  a  so-called  double  consciousness 
has  been  claimed  by  some  writers.  According  to  their 
assertion  there  are  individuals  who  periodically  fall  into 
a  state  of  impaired  or  altered  consciousness  during 
which  they  perform  certain  actions.  After  awaking  from 
such  a  state  they  do  not  remember  anything  that  has 
transpired  during  the  period.  This  alone  would  not  be 
very  strange,  for  something  similar  occurs  also  in  epilep- 
tics. But  what  is  remarkable  is  that  events  which  have 
taken  place  during  these  spells  can  be  recollected  only  in 
subsequent  spells,  but  not  in  the  intervals.  The  same 
holds  good  conversely  of  the  intervals.  The  individual 
is  possessed,  as  it  were,  of  two  consciousnesses.  Each 
of  them  exists  at  a  different  time  and  has  a  memory  for 
itself,  but  not  for  its  fellow,  so  that  the  individual  is  able 
to  recollect  events  which  have  occurred  in  the  state  of 
one  consciousness,  only  in  a  repeated  state  of  the  same 
consciousness.  But  all  the  reports  of  this  nature  which 
have  been  adduced  to  confirm  the  theory,  have  not  been 
convincing. 

In  epilepsy  states  of  clouded  consciousness  occur 
which  have  been  called  the  psychic  equivalents  of  the 
epileptic  attacks.  They  have  been  explained  in  the  fol- 
lowing way:  Epileptics  are  sometimes  subject  to  spells 
in  which  the  motor  sphere  k>  not  affected  and  only  their 
consciousness  undergoes  a  change,  while  the  ordinary, 
completely  developed  attacks  consist  in  both  convulsions 
and  loss  of  consciousness  (pp.  243-244).  In  these  semi- 
conscious  states   the   epileptics   may   commit   dangerous 


GENERAL  PATHOLOGY  93 

acts.  The  psychic  equivalents  are  met  with  especially 
in  traumatic  epilepsy  coming  on  after  the  age  of  20 
years.  Although  consciousness  is  not  entirely  lost  in 
the  psychic  equivalents,  the  patients  do  not  recognize 
their  surroundings  and  have  afterwards  a  gap  of  mem- 
ory for  the  whole  time  the  spell  has  lasted. 

Similarly  hysterical  patients  are  subject  to  spells  of 
disturbed  consciousness. 


Chapter  XLVL 

DISTURBANCE  OF  CONSCIOUSNESS  IN  GENERAL 
PARESIS  AND  IN  DELIRIA. 

Disturbance  of  consciousness  is  quite  frequent  in 
the  course  of  general  paresis.  The  patients  are  seized 
with  attacks  either  of  apoplectiform  or  of  epileptiform 
character.  In  the  first  case  they  suddenly  fall  to  the 
ground  and  lose  consciousness,  creating  the  impression 
that  a  cerebral  hemorrhage  has  taken  place.  But  this  is 
usually  not  the  case.  For,  in  the  first  place,  the  attack 
is  evanescent,  the  patients  usually  recovering  within  a 
very  short  time.  Secondly,  in  case  of  death  a  hem- 
orrhage cannot  be  demonstrated  in  the  brain  at  the 
autopsy.  The  epileptiform  attacks  of  the  paretics  are 
characterized  by  loss  of  consciousness  associated  with 
convulsions  in  a  manner  similar  to  the  attacks  of  the 
epileptics. 

Consciousness  is  disturbed  in  delirious  states. 
These  are  generally  of  toxic  origin,  as  the  deliria  in  the 
course  of  the  acute  infectious  diseases,  in  which  they 
are  caused  by  toxines,  and  the  deliria  of  drug  poison- 


94  PSYCHE 

ing,  as  in  morphine,  atropine,  cocaine  poisoning  and  in 
chronic  alcoholism. 


Chapter  XLVIL 
DISTURBANCE  OF  SELF=CONSCIOUSNESS. 

Disturbance  of  self -consciousness  is  frequently  met 
with  in  many  psychoses.  Self -consciousness  has  been 
defined  as  the  individual's  judgment  about  his  own  per- 
sonality whereby  he  recognizes  his  relation  to  the  ex- 
ternal world  (p.  28).  When,  therefore,  insane  patients, 
due  to  a  morbid  affective  state  or  to  delusions,  overesti- 
mate or  underestimate  themselves,  as  is  the  case  with 
maniacs,  melancholies,  paranoiacs,  etc.,  they  are  affected 
with  impairment  of  self-consciousness. 

When  patients  fail  to  recognize  their  relation  to 
the  external  world,  especially  when  they  lack  the  proper 
comprehension  of  time  and  space,  we  speak  of  disorien- 
tation. Disorientation  may  be  due  to  defects  of  memory 
and  judgment,  to  hallucinations,  and  to  delusions. 


SECTION  V. 
SOMATIC  DISTURBANCES  IN  THE  INSANE. 

Remark.  In  all  exactness  mental  disorders  are  somatic  dis- 
turbances. For  ultimately  they  are  due  to  some  pathological 
process  going  on  in  the  brain,  an  organ  of  the  body.  But  in  a  more 
restricted  sense  somatic  disturbances  are  taken  to  be  those  physical 
anomalies  which  have  no  direct  relation  to  the  psychical  functions 
of  the  brain,  and  yet  are  frequently  met  with  in  patients  suffering 
from  mental  diseases. 


Chapter  XLVIII. 

DISTURBANCE  OF  SLEEP  AND  OF  THE  GENERAL 
NUTRITION,   SITOPHOBIA. 

Sleep,  as  has  been  shown  before  (p.  90),  is  fre- 
quently impaired  in  psychoses.  Insomnia  is  present  in 
the  beginning  of  almost  every  acute  mental  malady. 
The  sleep  of  some  patients  lacks  the  refreshing  char- 
acter of  the  sleep  of  the  sane,  and  is  reduced  in  intensity 
and  duration.  On  the  other  hand,  there  are  instances  in 
which  the  sleep  of  the  insane  lasts  much  longer  than  the 
sleep  of  healthy  individuals,  so  that  the  patients  are  for 
days  and  weeks  in  a  continual  state  of  somnolence.  In 
some  patients  this  is  due  to  hemorrhages  in  the  dura 
mater  (pachymeningitis  haemorrhagica).  The  blood 
extravasate  exerts  a  pressure  on  the  cerebral  cortex,  thus 
producing  a  constant  state  of  drowziness.  At  the  au- 
topsy rust-colored  membranes  of  considerable  thickness 
are  found  on  the  brain. 

The  general  nutrition  of  the  insane  is  very  often 
impaired.      With   the   onset   of   a   psychosis   the   bodily 


96  PSYCHE 

weight  of  the  patient  decreases  to  rise  again  with  the 
beginning  of  convalescence  or  of  the  terminal  incurable 
stage.  In  some  patients  the  hair  becomes  gray.  This 
canities  is  probably  due  to  neurotic  influences.  It  is  of 
common  repute  that  care  and  worry  render  the  hair  gray. 
When  the  patients  recover,  the  hair  may  assume  its 
original  color.  The  nutrition  of  the  skin  is  sometimes 
reduced  as  manifested  by  dryness,  diminished  elasticity, 
and  scaling  of  the  epidermis.  The  nails  become  discol- 
ored, thinner,  and  show  grooves.  The  number  of  the 
latter  has  been  taken  by  some  as  an  indication  of  the 
number  of  attacks  a  patient  has  passed  through. 

The  impaired  nutritive  state  of  the  insane  is  fre- 
quently due  to  sit 0 phobia.  Some  patients  have  a  horror 
of  food  and  refuse  it  for  so  long  a  time  that  they  may 
actually  die  of  starvation.  Melancholies  reject  food, 
dominated  by  the  delusion  of  not  being  worthy  of  nour- 
ishment. Paranoiacs  decline  to  eat  becaUvSe  of  gustatory 
hallucinations  or  because  of  the  delusion  that  their  food 
contains  poison.  Other  patients  refuse  food  because 
they  have  noticed  that  their  anxiety  and  fear  increase 
when  their  stomach  is  filled.  Hypochondriacal  patients 
imagine  that  they  have  no  stomach,  that  the  food  goes 
directly  into  the  abdominal  cavity,  and  try  to  avoid  this 
danger  by  abstaining  from  eating.  Other  patients  try 
to  carry  out  suicidal  plans  by  refusal  of  food.  Finally 
stuporous  and  some  demented  patients  take  no  nourish- 
ment for  want  of  any  feeling  of  hunger  or  because  they 
are  unable  to  carry  out  the  movements  necessary  for  tak- 
ing food. 

We  may  mention  in  passing  the  impairment  of  the 
nutritive  state  due  to  overfeeding,  found  chiefly  in  vari- 
ous dementias. 


GENERAL  PATHOLOGY  97 

Chapter  XLIX. 
MOTOR    DISTURBANCES. 

Motor  disturbances  are  not  infrequent  in  psychoses. 
They  are  of  great  diagnostic  value.  The  condition  of 
the  pupils  furnishes  significant  hints.  In  examining  the 
pupils  we  must  observe  whether  they  are  large  or  nar- 
row, equal  or  unequal,  and  whether  they  react  to  light 
promptly,  sluggishly,  or  not  at  all.  A  difference  in  size 
of  the  pupils  without  any  other  symptom  does  not  reveal 
which  of  the  two  is  the  affected  pupil.  If  one  pupil  is 
remarkably  narrow  or  remarkably  wide,  we  may  be 
inclined  to  consider  this  the  abnormal  one.  In  such  a 
case  the  mobility  of  the  pupils  decides;  that  pupil  is 
less  affected  which  contracts  better  and  more  readily 
when  light  is  thrown  into  the  eye  and  conversely.  The 
reaction  of  the  pupils  is  more  important  than  a  differ- 
ence in  size.  Rigidity  of  the  pupils  to  light  and  not  to 
accommodation — Argyle-Robertson  pupil — is  of  omin- 
ous significance  as  it  indicates  tabes  or  general  paresis. 

Disturbance  of  the  innervation  of  the  tongue,  occur- 
ing  in  the  insane,  is  recognized  chiefly  by  faulty  articula- 
tion. Impaired  innervation  of  the  facial  muscles  is  seen 
in  paretics.  It  also  contributes  to  render  the  articula- 
tion defective. 

Some  insane  patients  are  affected  with  pareses  and 
paralyses  of  the  extremities.  Other  patients  show  an 
oblique  posture  of  the  body,  or  a  defective  gait,  one  leg 
being  dragged  along.  Closer  examination  of  these  pa- 
tients reveals  that  they  have  no  true  pareses.  Their 
motor  irregularities  are,  therefore,  to  be  considered  as 
a  disturbance  of  the  bodily  equilibrium. 

Disorders  of  the  bladder  occur  in  some  psychoses. 


98  PSYCHE 

It  can  not  be  evacuated  so  that  the  urine  is  stowed  up  to 
the  renal  pelvis.  This  may  give  rise  to  an  ascending 
inflammation  of  bladder,  ureters,  and  kidneys — pyelone- 
phritis. 


Chapter  L. 
DISTURBANCE   OF   SENSIBILITY. 

The  occurrence  of  decubitus  in  insane  patients  has 
been  ascribed  to  tropho-neurotic  disorders.  But  the 
cause  of  the  decubitus  seems  to  be  rather  the  result  of 
long  lasting  pressure  on  the  skin.  The  sane  person, 
while  sitting  or  lying,  does  not  keep  up  exactly  the  same 
posture  uninterruptedly  for  a  long  time ;  he  turns  a  litttle 
from  side  to  side,  he  shifts  his  position  frequently.  In 
this  way  the  skin  does  not  remain  for  too  long  a  time 
under  undue  pressure.  The  sane  person  has  a  delicate 
sense  of  pressure  so  that  even  in  sleep  he  becomes  aware 
of  it  and  lessens  it  by  slight  changes  of  position.  In  the 
insane  this  finer  feeling  is  lacking.  They  remain  mo- 
tionless for  many  hours  and  thus  gangrene  of  the  skin 
may  be  produced.  It  can  easily  be  proved  that  tropho- 
neurotic influences  are  not  the  cause  of  the  decubitus  of 
the  insane.  In  almost  every  case  of  decubitus  long  last- 
ing pressure  on  the  skin  can  be  demonstrated,  the  decu- 
bitus is  never  symmetrical,  and  the  wound,  with  the 
proper  treatment,  heals  as  readily  as  in  a  healthy  person. 
Finally  the  decubitus  can  be  prevented  by  protecting  the 
patients  against  long  lasting  pressure.  The  decubitus  of 
the  insane  is,  therefore,  not  brought  about  by  paralysis 
of  trophic  nerves,  but  is  caused  by  anaesthesia  of  the 
skin  in  consequence  of  which  the  patients  make  no  effort 


GENERAL  PATHOLOGY  99 

t(;  shun  the  injurious  elYect  of  long  lasting  pressure  on 
the  skin. 

Anaesthesia  of  the  skin  is  frequently  met  with  in 
paretic  patients.  They  may  pierce  their  skin  with  a 
needle  without  manifesting  a  feeling  of  pain.  Some- 
thing similar  is  observed  in  hysteria.  Owing  to  this 
anaesthesia  some  patients  may  contract  burns,  blisters, 
etc. 


Chapter  LL 
DISTURBANCE  OF  THE  ACTIVITY  OF  THE  HEART. 

Some  writers  have  asserted  that  the  insane  are 
affected  with  a  characteristic  disorder  of  the  heart. 
While  normally  the  pulse  curve  is  "tricrotic,"  the  insane 
have  a  ''tardy"  pulse  curve.  Normally  there  is  a  rapid 
and  immediate  decrease  of  the  calibre  of  the  artery  after 
its  first  distention  through  the  blood  wave ;  in  the  ''pulsus 
tardus,"  however,  the  arterial  calibre  diminishes  grad- 
ually after  its  first  dilatation  (O.  T.  B.  Wolff).  But  al- 
though the  "tardy"  pulse  is  found  in  the  insane  so  often 
that  we  may  be  tempted  to  regard  it  as  a  pathognomonic 
sign  of  insanity,  a  closer  investigation  has  demonstrated 
that  it  is  not  characteristic  of  mental  disease.  The  tardy 
pulse  is  not  caused  by  paralysis  of  vasomotor  nerves,  as 
has  been  assumed,  but  is  rather  due  to  weakness  of  the 
heart  and  increased  resistance  in  the  circulation  at  the 
periphery.  The  tardy  pulse  is  met  with  not  only  in  psy- 
choses, but  also  in  other  diseases  in  which  these  two 
factors  are  present. 


PART  III.  .    \ 


ETIOLOGY   OF   INSANITY 


Chapter  LIL 
CLASSIFICATION  OF  THE  CAUSES  OF  INSANITY. 

Insanity — psychosis,  alienation — is  a  disease  of  the 
brain,  especially  of  the  brain  cortex,  deranging  its  mental 
functions,  such  as  perceiving,  feeling,  thinking,  willing, 
acting,  to  such  an  extent  that  the  patient  is  unable  to 
adapt  himself  to  his  environment. 

Many  causes  have  been  advanced  for  insanity,  yet 
its  etiology  is  resting  on  a  very  uncertain  basis. 

The  causes  of  insanity  are  either  predisposing  or 
exciting.  Most  of  them  are  both,  e.  g.,  traumatism. 
Some  causes  may  be  regarded  only  as  predisposing,  e.  g., 
heredity.  A  physical  injury  may  lower  the  organism's 
power  of  resistance.  The  acquired  weakness  has  the 
result  that  at  a  much  later  period  insanity  breaks  out  in 
direct  consequence  of  some  severe  general  disease,  as 
typhoid  fever.  In  such  a  case  the  trauma  is  the  predis- 
posing, the  typhoid  fever  the  exciting  cause.  On  the 
other  hand,  a  patient  whose  system  has  been  weakened  by 
some  grave  disease  falls  readily  a  victim  of  insanity 
when  he  receives  a  serious  injury.  In  this  instance  the 
trauma  is  the  exciting  cause. 

In  general  it  may  be  stated  tliat  anything  capable 
of  injuring  the  general  health  is  also  apt  to  exert  an 
injurious  influence  on  the  resistibility  and  soundness  of 
the  central  nervous  system  and  in  tliis  way  may  ])ecome 
the  cause  of  insanitv. 


I04  PSYCHE 

Chapter  LIII. 
INFLUENCE   OF   CIVILIZATION. 

Civilization  has  been  considered  a  predisposing 
factor  of  insanity.  As  a  proof  for  this  view  has  been 
adduced  the  observation  that  in  civiHzed  states  insanity 
is  more  frequent  than  among  unciviHzed  peoples.  But 
the  correctness  of  this  observation  is  questionable,  for  it 
is  based  on  faulty  statistics.  The  number  of  insane  in 
every  thousand  inhabitants  has  been  counted — in  savage 
tribes  it  has  been  taken  as  reported  by  travellers — and 
found  to  be  lower  in  savage  tribes  than  in  civilized  na- 
tions. The  conclusion  has  thereupon  been  made  that  in- 
sanity is  rarer  among  the  former  than  among  the  latter, 
and  civilization  has  been  assumed  to  be  responsible  for 
this  condition.  But  the  argument,  striking  as  it  may 
appear,  contains  the  fallacy  that  statistics  themselves  are 
a  product  of  civilization.  The  statistical  apparatus  is 
very  much  finer  in  civilized  states  than  in  primitive  tribes, 
and  with  a  better  apparatus  higher  numbers  will  be 
found.  To  establish  reliable  statistics  of  the  psychoses 
first  of  all  investigators  are  needed,  capable  of  recogniz- 
ing or  diagnosing  them.  Correct  statistics  depend  chiefly 
upon  the  skill  and  accuracy  with  which  the  work  is  done, 
and  in  civilized  states  these  means  are  more  easily  ob- 
tained. 

Another  proof  has  been  advanced  to  show  that  in- 
sanity has  increased  with  the  growth  of  civilization. 
Formerly  there  were  hardly  any  asylums  for  the  insane, 
nowadays  there  are  many  and  all  are  overcrowded. 
Hence  the  number  of  the  insane  has  become  larger.  This 
argument  is  rather  weak.  For  in  those  times  when  there 
were  no  insane  asylums  many  cases  of  insanity  did  not 


ETIOLOGY  OF  INSANITY.  105 

come  to  the  knowledge  of  the  authorities.  With  the  bad 
treatment  they  obtained  from  relatives  and  neighbors, 
the  mortality  of  the  insane  was  enormous.  Compassion 
was  accorded  them,  but  it  went  only  as  far  as  the  purse 
and  there  it  stopped.  Nowadays  millions  are  spent  for 
the  unfortunates.  Moreover,  the  diagnosis  of  the  psy- 
choses was  very  little  developed  and  many  cases  of  in- 
sanity remained  unrecognized  on  this  account.  Now- 
adays there  are  physicians  specially  skilled  in  the 
diagnosis  and  treatment  of  mental  disease,  and  the  pa- 
tients who  have  not  yet  lost  their  free  will  call  upon  them 
and  complain  about  their  hallucinations,  compulsory 
ideas,  feelings  of  anxiety  and  fear,  etc.,  and  seek  their 
help. 

Further,  to  demonstrate  the  influence  of  civilization 
upon  insanity,  the  interdependence  of  psylchoses  and  sui- 
cide has  been  pointed  out. .  Indeed,  most  of  the  suicide 
cases  are  of  morbid  nature.  The  statistics  of  suicide  are 
quite  exact  and  reliable.  There  is  hardly  any  error  made 
in  establishing  the  frequency  of  suicide,  though  rarely  it 
is  made  a  cloak  for  a  crime.  Now,  statistics  have  shown 
a  decided  increase  of  suicide  with  the  advance  of  civiliza- 
tion. It  may,  therefore,  be  said  that  the  psychoses  show- 
ing a  close  relation  to  suicide  have  also  increased  through 
civilization.     This  argument  is  somewhat  conclusive. 

The  effect  of  civilization  upon  the  frequency  of  gen- 
eral paresis  after  syphilitic  infection  has  been  investigated 
by  some  writers  who  find  that  the  percentage  is  increased 
in  civilized  lands. 

Bearing  in  mind  the  preceding  considerations  we  are 
led  to  the  conclusion  that  the  psychoses  have  increased 
with  the  progress  of  civilization,  with  the  growth  of 
population    and    the    consequent    intensification    of    the 


io6  PSYCHE 

struggle  for  existence,  and  with  the  enhancement  of  the 
propensity  for  enjoyment  and  pleasure,  due  to  civiliza- 
tion. But  this  increase  is  not  as  considerable  as  may 
appear  from  statistics  and  from  the  records  of  the  insane 
asylums. 


Chapter  LIV. 
INFLUENCE  OF  RELIGION. 

The  question  has  been  raised  whether  religious 
creed  has  any  influence  on  insanity;  for  in  certain  lo- 
calities more  insane  have  been  found  among  the  adher- 
ents of  one  creed  than  among  the  other  inhabitants.  But 
this  fact  does  not  justify  the  general  conclusion  that  it 
is  due  to  religion  as  such.  When  in  a  community  among 
the  Catholics,  for  instance,  there  are  more  insane  patients 
than  among  the  Protestants  and  Jews,  this  does  not  prove 
that  creed  as  such  is  the  cause.  Another  factor,  which 
has  reference  to  religious  creed  only  in  an  indirect 
way,  plays  an  important  part.  This  factor  is  marriage 
between  blood-kindred.  The  children  from  such  mar- 
riages are  frequently  afflicted  with  nervous  diseases,  with 
hysteria,  neurasthenia,  epilepsy,  psychoses.  Now,  if  in 
a  province  the  adherents  of  one  creed  are  in  considerable 
minority,  many  more  intermarriages  will  occur  between 
them  than  among  the  members  of  the  other  creeds.  The 
consequence  will  be  that  they  will  furnish  a  compara- 
tively larger  number  of  insane  than  the  rest  of  the  popu- 
lation. 

It  has  been  maintained  that  the  Jews  have  a  greater 
predisposition  to  insanity  than  the  adherents  of  other 
creeds.     But  from  comparative  number  alone  a  correct 


ETIOLOGY  OF  INSANITY.  107 

conclusion  cannot  be  drawn.  Other  factors,  too,  have  to 
be  considered.  It  is  a  fact  that  the  Jewish  families  are 
more  solicitous  for  their  insane  patients  than  families  of 
other  creeds.  The  peasant  families  in  Europe,  for  in- 
stance, are  very  indifferent  in  the  care  of  their  sick,  espe- 
cially of  their  insane  relatives,  as  long  as  no  danger 
menaces  their  homes.  The  Jews,  in  their  honor  it  must 
be  said,  act  quite  differently.  They  are  more  easily  con- 
vinced by  the  physician  that  danger  is  imminent.  They 
are  readily  willing  to  go  to  great  expenses  for  the  sani- 
tary welfare  of  their  own.  These  factors  must  not  be 
overlooked.  They  are  of  great  importance  in  determin- 
ing the  comparative  prevalence  of  insanity  among  the 
Jews.  Although  it  cannot  be  denied  that  insanity  is  com- 
paratively more  frequent  among  them,  it  does  not  go  as 
far  as  has  been  maintained. 


Chapter  LV. 
HEREDITY. 

Heredity  represents  a  very  important  etiological 
factor  of  insanity,  predisposition  to  mental  disease  being 
more  frequently  due  to  hereditary  than  to  any  other 
causes. 

It  happens  quite  often  that  parents  and  children  or 
several  brothers  and  sisters  are  afflicted  with  insanity. 
The  assumption  of  a  hereditary  cause  appears  to  be  very 
much  justified  in  such  cases.  And  indeed,  it  has  long  been 
established  that  the  descendants  of  the  insane  acquire 
mental  diseases  more  readily  than  the  offspring  of  sane 
people.  Frequently  in  a  family  with  a  history  of  insanity 
several  members  become  insane,  others  neurasthenic,  hys- 


io8  PSYCHE 

terical,  epileptic,  addicted  to  alcohol,  another  commits  sui- 
cide, again  another  is  of  an  eccentric  character,  finally 
one  distinguishes  himself  through  extraordinary  intel- 
lectual gifts.  In  taking  the  anamnesis  of  a  patient  it  is, 
therefore,  necessary  to  inquire  not  only  after  a  history 
of  insanity,  but  also  of  such  abnormal  family  traits. 

Extraordinary  intellectual  gift,  as  a  sign  of  her- 
editary predisposition  to  insanity,  has  to  be  taken  cum 
grano  salis.  It  is  going  too  far  to  maintain  unrestrict- 
edly that  the  offspring  of  geniuses  are  predisposed  to 
insanity.  We  only  may  say  that  one-sided  geniuses  may 
transmit  hereditary  predisposition  to  insanity.  For  while 
in  one  respect  they  display  extraordinary  intellectual  ca- 
pacity, in  other  respects  they  are  not  free  from  mental  de- 
fects. In  the  one-sided  geniuses,  as  it  were,  a  compen- 
satory development  of  some  mental  faculties  has  taken 
place  at  the  expense  of  the  others.  But  if  a  person  is 
descended  from  a  many-sided  genius,  he  is  to  be  con- 
gratulated. For  he  may  have  inherited  precious  intel- 
lectual gifts  and  great  power  of  resistance  of  the  central 
nervous  system,  since  he  comes  from  an  ancestor  who 
was  endowed  with  these  excellent  qualities. 

The  foregoing  remarks  may  be  summarized  as  fol- 
lows: Through  heredity  insanity  is  not  transmitted  di- 
rectly, but  only  a  certain  predisposition  to  mental  disease 
is  inherited.  Psychopathic  predisposition  in  a  family  is 
indicated  not  only  by  a  history  of  insanity,  but  also  of 
neurasthenia,  hysteria,  epilepsy,  drunkenness,  suicide, 
crime,  eccentricity,  unusual  one-sided  intellectual  gifted- 
ness. 

A  person  may  have  hereditary  predisposition  to  in- 
sanity without  ever  acquiring  a  psychosis,  but  he  may 
transmit  his  psychopathic  predisposition  to  his  offspring. 


ETIOLOGY  OF  INSANITY.  109 

so  that  mental  disease  makes  its  appearance  in  the  third 
or  even  in  a  later  generation. 

When  a  person  is  descended  from  insane  parents, 
his  hereditary  predisposition  is  greater  than  when  the 
parents  were  sane  and  only  a  grand  parent  or  a  great 
grand  parent  was  afflicted  with  insanity.  When  both 
parents  have  been  insane,  the  children  are  more  predis- 
posed to  mental  disease  than  when  only  one  parent  has 
had  a  psychosis.  Insanity  among  lineal  relations  renders 
the  psychopathic  predisposition  greater  than  insanity 
among  collateral  relations.  Hence  there  is  a  manifold 
gradation  in  the  intensity  of  hereditary  predisposition  to 
insanity. 

If  insanity  has  occurred  among  lineal  relations,  there 
is  a  direct  family  history  of  insanity,  but  if  only  collateral 
relations  have  been  affected  with  psychoses,  the  family 
history  of  insanity  has  been  designated  as  indirect. 

A  family  history  of  insanity  in  descending  line  has 
also  been  spoken  of.  This  sounds  rather  strange,  but  is 
to  be  understood  in  the  following  way.  When  the  chil- 
dren become  mentally  ill,  the  assumption  is  made  that 
the  parents  have  transmitted  to  them  a  predisposition  to 
insanity,  although  no  direct  or  indirect  cases  of  psychoses 
can  be  traced  in  the  family.  Later  on  a  psychosis  breaks 
out  in  one  of  the  parents  and  the  assumption  becomes 
true.  The  hereditary  predisposition  was,  therefore,  not 
lacking,  but  it  became  manifest  in  the  progenitors  later 
than  in  the  descendants.  The  anamnesis  in  the  case  of 
the  former  gives  a  family  history  of  insanity  in  descend- 
ing line. 

Not  all  the  children  of  a  family  possess  the  her- 
editary predisposition  in  the  same  degree.  Those  chil- 
dren have  the  greatest  predisposition  whose  birth  is  least 


no  PSYCHE 

remote  from  the  date  of  the  illness  of  the  parents.  If 
the  parents  have  a  family  history  of  insanity,  but  have 
never  had  a  psychosis,  the  children  born  last  have  a 
greater  hereditary  predisposition  than  those  born  first. 
It  is  possible  that  the  first  born  child  remains  sane  all 
through  life,  the  second  shows  a  manifest  predisposition 
to  insanity — which  will  be  treated  later — and  the  third 
becomes  insane  in  early  youth.  There  is,  therefore,  a 
great  number  of  gradual  differences  in  hereditary  pre- 
disposition to  insanity,  and  this  fact  is  of  practical  impor- 
tance. 

The  number  of  insane  patients  who  have  a  family 
history  of  insanity  is  easy  to  establish.  In  the  insane 
asylums  such  a  history  can  be  demonstrated  in  75  per 
cent,  of  the  cases.  The  conclusion  has  thereupon  been 
made  that  of  100  people  with  a  family  history  of  insanity 
75  acquire  psychoses.  This  conclusion  is  fallacious.  For 
to  determine  how  many  of  those  giving  a  family  history 
of  insanity  become  mentally  sick,  the  question  has  first 
to  be  decided  how  many  people  in  the  whole  population 
have  such  a  history.  Otherwise  the  problem  can  hardly 
be  solved.  The  investigation  of  this  question  is  ex- 
tremely difficult  because  many  families  conceal  their 
cases  of  insanity. 


Chapter  LVI. 

STIGMATA  OF  HEREDITARY  PREDISPOSITION  TO 
INSANITY. 

The  question  has  been  raised  whether  hereditary 
predisposition  to  insanity  can  be  assumed  only  in  those 
instances  in  which  cases  of  insanity,  epilepsy,  drunken- 


ETIOLOGY  OF  INSANITY.  iii 

ness,  etc.,  have  occurred  among  lineal  or  collateral  rela- 
tions, or  whether  also  without  such  data  hereditary  pre- 
disposition can  be  concluded  from  physical  anomalies. 
Certain  abnormal  features  of  the  body,  called  stigmata, 
have  been  found  in  individuals  with  a  family  history  of 
insanity  and  have  been  designated  as  manifest  hereditary 
predisposition  in  contradistinction  to  latent  hereditary 
predisposition  ascribed  to  those  cases  in  which  such  stig- 
mata are  absent. 

Some  individuals  with  a  history  of  insanity  show 
deformities  of  the  skull,  such  as  asymmetry  or  obliquity. 
The  left  half  of  the  forehead,  for  instance,  is  retracted, 
and  at  the  same  time  the  left  half  of  the  occiput  pro- 
trudes backwards.  This  may  indicate  that  the  develop- 
ment and  growth  of  the  cranium  and  brain  have  been 
disturbed.  An  eventual  autopsy  reveals  that  a  cranial 
suture  has  not  been  closed,  or  that  a  suture  which  is  nor- 
mally serrated  has  remained  smooth,  etc. 

The  facial  part  of  the  skull  also  shows  develop- 
mental disturbances,  especially  the  upper  jaw.  Some- 
times the  suture  of  the  palate  is  not  situated  in  the  me- 
dian line,  or  the  vault  of  the  palate  is  remarkably  flat  or 
remarkably  narrow  and  high.  In  other  cases  there  is 
prognathism;  normally  the  upper  incisive  teeth  stand  just 
a  little  more  forward  than  the  lower  incisors;  in  pro- 
nounced prognathism,  however,  the  upper  incisors  pro- 
trude so  far  that  a  finger  can  be  put  between  them  and 
the  lower  ones. 

Faulty  shape  of  the  external  ear,  as  lack  of  the  helix 
("rat's  ear")  or  tragus,  rudimentary  ear  lap,  etc.,  have 
been  brought  into  relation  to  hereditary  predisposition. 
Some  dispute  the  connection  between  the  two.  But  sta- 
tistics have  shown  that  deviations  from  the  normal  con- 


112  PSYCHE 

figuration  of  the  external  ear  are  found  more  often 
in  those  giving  a  family  history  of  insanity  than  in 
others. 

Developmental  disturbances  of  the  eyes  are  also  met 
with  in  individuals  with  a  family  history  of  insanity, 
such  as  formations  of  clefts  in  iris  and  chorioidea — colo- 
bomata — excessive  hypermetropia  indicating  insufficient 
development  and  growth  of  the  orbita. 

Congenital  hernias,  fissures  of  scrotum  and  urethra, 
hypospadia,  clubfoot,  etc.,  have  been  considered  as  signs 
of  arrest  of  development  and  a  manifest  hereditary  pre- 
disposition to  insanity  has  been  ascribed  to  individuals 
showing  these  congenital  anomalies.  But  nowadays  the 
view  prevails  that  these  deformities  may  have  an  external 
cause  and  are  of  little  importance. 

The  abnormal  features  mentioned  before  are  all 
physical  stigmata.  But  also  mental  stigmata  have  been 
described.  It  has  been  maintained  that  hereditary  pre- 
disposition to  insanity  is  indicated  by  extreme  nervous 
irritability,  fickleness,  retiring  disposition,  secretiveness, 
frequent  emotional  spells  with  lack  of  self-control, 
etc. 

Whether  the  mental  and  physical  features  described 
above  as  stigmata  have  any  relation  to  insanity  must  be 
left  undecided.  Only  this  one  fact  remains  certain  that 
individuals  among  whose  relations  there  have  been  cases 
of  insanity,  epilepsy,  drunkenness,  suicide,  etc.,  are  un- 
questionably predisposed  to  mental  disease.  But  it  is  to 
be  borne  in  mind  that  one  affected  with  manifest  her- 
editary predisposition  and  even  giving  a  family  history 
of  insanity  must  not  necessarily  acquire  a  psychosis, 
but,  leading  a  normal  quiet  life,  may  always  remain 
sane. 


ETIOLOGY  OF  INSANITY.  113 

Chapter  LVII. 
PSYCHICAL  INFLUENCES. 

Certain  influences  on  the  mind  are  apt  to  cause  in- 
sanity. They  may  be  of  agreeable  or  disagreeable  nature. 
Among  the  latter  are  to  be  counted  fright,  anxiety,  worry, 
care  of  sustenance,  death  of  a  near  relative,  vexation 
about  having  been  refused  appreciation,  about  violation 
of  honor,  about  rejected  love,  etc.  To  the  agreeable  in- 
fluences belongs  joyful  surprise  through  incidents  which 
create  an  extraordinary  situation.  Great  good  fortune 
has  sometimes  proved  fatal  to  the  sanity  of  a  person, 
owing  to  his  inability  to  adapt  himself  quickly  enough  to 
the  new  conditions  into  which  he  has  been  unexpectedly 
placed.  The  resistance  of  the  central  nervous  system  is 
lowered  through  all  violent  agitations.  Sometimes  a 
psychosis  immediately  follows  a  mental  shock. 

Mental  strain,  especially  when  associated  with  phy- 
sical overexertion,  has  a  dangerous  effect  on  the  mind. 
Many  soldiers  who  take  part  in  military  expeditions  be- 
come insane.  For  the  hardships  of  war  consist  in  great 
physical  as  well  as  mental  exertion,  in  fatigue,  worry, 
anxiety,  etc.  Officers  become  victims  of  insanity  in  com- 
paratively larger  numbers  than  common  soldiers  because 
they  have  to  go  through  greater  mental  strain  than  the 
latter. 

Continued  mental  work  is  productive  of  insanity, 
especially  when  stimulants,  -such  as  alcohol,  tobacco, 
cocaine,  etc.,  have  been  used  to  keep  up  the  mental  ca- 
pacity. In  this  respect  it  is  of  importance  to  know  how 
long  the  stimulants  have  been  indulged  in.  If  it  can  be 
demonstrated  that  mental  exertion  was  connected  for 
many  years  with  the  habitual  use  of  stimulants,  the  lat- 


114  PSYCHE 

ter  is  also  to  be  counted  among  the  causative  factors 
when  a  psychosis  breaks  out. 

The  question  of  overburdening  the  children  in  the 
schools  may  be  mentioned  at  this  place,  for  owing  to  this 
factor  some  children  may  become  mentally  sick.  It  must 
be  admitted  that  the  same  tasks  are  burdensome  to  some 
pupils,  but  easy  to  others.  The  mental  capacity  of  the 
children,  therefore,  ought  to  be  considered  before  send- 
ing them  to  a  certain  school.  The  statement  can  justly 
be  made  that  the  overtaxing  of  some  pupils  is  not  to  be 
placed  at  the  door  of  the  schools,  but  is  to  be  put  to  the 
account  of  the  parents  who  send  their  children  to  schools 
the  requirements  of  which  they  are  unable  to  fulfill. 

The  influence  of  imprisonment  upon  the  mental 
health  belongs  to  this  chapter.  When  one  is  deprived  of 
his  liberty,  especially  when  he  is  put  in  solitary  confine- 
ment, he  begins  to  suffer  mentally.  Uneducated  prison- 
ers whose  funds  of  knowledge  are  too  meagre  to  afford 
them  entertainment  with  their  own  thoughts,  become  more 
readily  mentally  ill  than  more  intellectual  ones.  Another 
factor  contributing  to  produce  mental  disease  in  prison- 
ers is  the  poor  state  of  their  general  health  brought  about 
by  the  unfavorable  conditions  prevailing  in  prisons.  The 
general  nutrition  is  greatly  impaired,  owing  to  poor  food 
and  to  lack  of  fresh  air  and  light.  This  shows  itself  by 
considerable  loss  of  weight.  It  requires  the  indifference 
and  imperturbability  of  the  habitual  criminal  to  take  on 
weight  during  imprisonment.  Confinement  before  trial 
may  sometimes  produce  a  psychosis.  This  point  is  of 
great  importance  for  the  medico-legal  expert.  The  pris- 
oner may  have  been  perfectly  sane  at  the  time  of  com- 
mitting the  crime,  while  at  the  trial  he  is  mentally  de- 
ranged, owing  to  the  preceding  confinement. 


ETIOLOGY  OF  INSANITY.  115 

Chapter  LVIII. 
INFLUENCE    OF    INFECTIOUS    DISEASES. 

A  frequent  etiological  factor  of  insanity  are  the  in- 
fectious diseases,  as  typhoid  fever,  scarlatina,  cholera, 
etc.  Their  effect  on  the  central  nervous  system  is  two- 
fold. In  the  first  place  they  cause  acute  poisoning 
through  toxines  which  act  on  the  brain,  giving  rise  to 
acute  mental  disturbances  in  the  form  of  deliria.  The 
latter  have  formerly  been  attributed  merely  to  the  high 
temperature.  But  the  rise  of  temperature  alone  is  not 
sufficient  to  explain  the  so-called  fever  deliria.  For  some 
patients  with  high  temperature  are  little  benumbed,  while 
others  with  low  fever  may  exhibit  strong  mental  aliena- 
tion. 

Secondly,  the  infectious  diseases  have  a  more  perma- 
nent weakening  effect  on  the  nervous  system,  so  that  the 
patients  retain  a  predisposition  to  mental  disease  and  thus 
acquire  psychoses  at  a  later  period.  Just  as  diphtheria 
even  of  slight  severity  may,  months  later,  give  rise  to 
diphtheritic  paralyses,  so  may  psychoses  appear  long 
after  the  infectious  diseases.  The  patient  may  overcome 
his  illness  with  comparative  ease,  but  as  a  consequence 
his  nervous  system  may  retain  diminished  resistibilty  to 
external  influences. 

Mental  disorders  occur  in  early  and  late  stages  of 
lues.  In  general  paresis — and  similarly  in  tabes — the 
percentage  of  cases  in  which  there  is  a  history  of  syph- 
ilitic infection  is  so  high  that  these  diseases  have  come 
to  be  regarded  as  late  luetic  manifestations.  Some,  how- 
ever, have  held  the  view  that  general  paresis  and  tabes 
do  not  represent  luetic  symptoms,  and  have  given  an- 
other explanation  for  the  frequent  occurrence  of  these 


ii6  PSYCHE 

diseases  in  syphilitics.  They  compare  the  effect  of  lues 
on  the  system  to  that  produced  by  the  acute  infectious 
diseases.  As  in  these  so  also  in  lues  the  resistibility  of 
the  system  is  greatly  reduced  by  toxines  and  thereby  a 
strong  predisposition  to  nervous  diseases  is  imparted  to 
the  patients.  The  fact  that  lues  can  be  excluded  in  a  fair 
percentage  of  cases  seems  to  justify  this  view.  The  latter 
will  hardly  agree  with  the  results  of  recent  sero-diag- 
nostic  investigations.  For  some  authors  maintain  that 
the  sero-diagnostic  examination  of  the  blood  and  the 
cerebro-spinal  fluid  of  paretics  shows  a  positive  syphilitic 
reaction  in  lOO  per  cent,  of  the  cases.  But  since  these 
findings  have  not  yet  been  fully  corroborated,  the  above 
view  is  not  untenable. 


Chapter  LIX. 
INFLUENCE  OF   POISONS. 

An  etiological  factor  of  insanity  is  furnished  by 
poisoning  with  various  organic  and  inorganic  substances. 
In  all  exactness,  the  effect  of  the  infectious  diseases  is  also 
of  a  poisonous — toxic — character;  at  least,  we  cannot 
explain  it  in  any  other  way.  They  might,  therefore,  as 
well  have  been  included  in  this  chapter.  But  while  the 
poisonous  substances  mentioned  here  are  well  known,  the 
toxines  of  the  infectious  diseases  have  not  yet  been  iso- 
lated, and  their  exact  nature  is  still  unknown.  This  is  the 
reason  why  their  influence  upon  the  mind  has  been  dis- 
cussed separately  from  other  poisons. 

Among  the  organic  poisons  alcohol,  in  the  form  of 
spirituous  liquors,  takes  the  first  place  in  the  causation 


ETIOLOGY  OF  INSANITY.  117 

of  insanity.  The  degree  of  the  alcoholic  concentration  is 
important,  whiskeys  and  brandies  being  more  injurious 
than  wine  and  beer,  heavy  wines  and  beers  more  deleteri- 
ous than  light  ones.  The  quality  of  the  alcoholic  bever- 
ages is  also  of  great  moment.  The  worse  the  brand  of 
the  liquor,  the  more  impurities  it  contains,  as  the  fusel 
oils,  and  the  more  harmful  it  is. 

Alcohol  has  first  an  acute  effect  on  the  mind.  In  a 
strict  sense,  the  alcohol  intoxication  represents  an  acute 
psychosis.  More  manifold  are  the  psychopathic  conse- 
quences of  chronic  abuse  of  alcohol.  The  chronic  al- 
coholic may  unexpectedly  become  insane  with  the  clin- 
ical picture  of  delirium  tremens  when  he  is  deprived  of 
his  habitual  stimulant.  The  deprivation  from  the  alcohol 
occurs  when  a  drunkard  is  arrested  and  put  into  prison. 
Delirium  tremens  may  break  out,  owing  to  the  lack  of 
the  stimulant.  The  prison  physician  ought,  therefore, 
to  see  to  it  that  alcoholics  just  made  prisoners  receive  a 
certain  amount  of  alcohol.  Another  occasion  in  which 
the  alcohol  is  suddenly  taken  away  from  drunkards  is  a 
physical  illness.  When  they  are  brought  into  the  hos- 
pital, and  they  themselves  are  not  even  able  to  ask  for 
alcohol,  they  may  be  seized  with  delirium  tremens  over 
night. 

Alcoholics  are  predisposed  to  many  diseases  and 
readily  become  victims  of  any  injurious  influences. 
Traumas  produce  mental  disturbances  in  inebriates  more 
frequently  than  in  temperate  people.  When  deprived  of 
their  liberty,  drunkards  succumb  to  the  deleterious  influ- 
ences of  prison  life  much  sooner  than  other  prisoners 
(p.  114). 

Mental  disorders  are  brought  about  through  poison- 
ing with  hypnotics  and  other  drugs,  such  as  morphine, 


ii8  PSYCHE 

opium,  chloral  hydrate,  cocaine,  atropine,  etc.  Chronic 
morphinism  has  become  quite  frequent  since  the  hypo- 
dermic injection  of  morphine  has  come  into  use,  the  med- 
ical profession  being  responsible,  to  a  great  extent,  for 
this  regrettable  fact.  Chloral  hydrate  is  often  pre- 
scribed for  insomnia.  Like  other  hypnotics  it  has  the  un- 
toward feature  that  the  organism  becomes  accustomed  to 
it.  Larger  and  larger  doses  have  to  be  taken  by  the  pa- 
tient, who  passes  sleepless  nights  without  the  remedy. 
After  long  use  mental  disorders  similar  to  those  of 
chronic  morphinism  make  their  appearance.  Acute  poi- 
soning with  cocaine  causes  agitation,  inhibition  of  speech 
and  of  thinking,  stupefaction,  etc.  The  chronic  abuse  of 
cocaine  is  productive  of  mental  disorders  and  marasmus 
and  brings  about  the  fatal  end  much  sooner  than  chronic 
morphinism.  Atropine  in  large  doses  causes  deliria,  so 
does  iodoform  after  protracted  application.  Poisoning 
with  mercury,  lead,  arsenic  also  produces  mental  distur- 
bances. Secale  cornutum  is  to  be  mentioned  here.  Flour 
corrupted  with  this  parasitic  fungus  brings  about  a  dis- 
ease similar  to  general  paresis.  In  provinces  where  much 
maize  is  consumed  insanity  is  quite  frequent — pellagra. 


Chapter  LX. 
INFLUENCE  OF  TRAUMA. 

Physical  injuries,  especially  of  the  skull,  play  an 
important  role  in  the  etiology  of  insanity.  All  violent 
commotions  of  the  body,  brought  about  by  fall  or  im- 
pact, are  apt  to  cause  neuroses  and  psychoses.  Fre- 
quently even  serious  injuries  remain  without  any  psycho- 


ETIOLOGY  OF  INSANITY.  119 

pathic  after-effects.  Many  a  head  has  received  blows  of 
no  little  force  without  the  slightest  mental  disorder  ap- 
pearing shortly  after  the  injury  or  at  a  later  period. 
Often  a  psychosis  follows  the  trauma  immediately. 
Sometimes,  however,  the  effect  of  a  trauma  upon  the 
mind  does  not  appear  before  many  years  have  elapsed. 
Some  disturbances  of  the  general  health  arise  immedi- 
ately after  the  injury,  such  as  headache,  sleeplessness, 
great  irritability,  intolerance  of  alcohol,  etc.  A  thread 
of  such  little  ailments  is  thus  spun  for  a  long  time  until 
the  outbreak  of  a  psychosis,    v 

In  trauma  as  an  etiological  factor  of  mental  disease, 
therefore,  cause  and  effect  may  lie  far  apart.  This  holds 
good  also  with  other  influences  productive  of  insanity. 
This  point  has  formerly  not  been  appreciated  sufliciently, 
and  therefore  the  influence  of  lues  has  been  overesti- 
mated. Many  a  psychosis  has  been  attributed  to  lues, 
although  its  cause  may  have  been  a  distant  trauma,  for- 
gotten long  ago,  or  a  severe  illness  which  the  patient  had 
been  afflicted  with  at  some  remote  period,  and  which  had 
diminished  the  resistibility  of  his  central  nervous  system. 

The  harmfulness  of  a  trauma  is,  as  a  rule,  directly 
proportionate  to  the  disturbance  of  consciousness  fol- 
lowing the  trauma,  so  that  the  more  the  consciousness  of 
the  patient  has  been  obtunded  by  the  injury,  the  more 
the  injury  is  likely  to  become  a  cause  of  insanity.  An 
error  may  be  committed  in  assuming  that  an  injury  has 
not  been  succeeded  by  disturbance  of  consciousness.  A 
patient  who  has  been  unconscious  after  a  violent  fall,  does 
often  not  know  anything  about  it,  unless  he  has  heard 
it  from  others.  Questioned  in  this  regard  he,  therefore, 
denies  having  been  unconscious  after  the  fall. 

Slight  injuries  without  disturbance  of  consciousness 


I20  PSYCHE 

may  also  be  of  serious  consequence  to  the  mental  health. 
Thus  an  injury  of  the  skull  may  leave  a  depressed  scar 
giving  rise  to  psychoses  many  years  later.  The  irritation 
of  the  cerebral  cortex  through  the  scar  may  produce  epi- 
leptic attacks  or  their  psychic  equivalents  (pp.  243-244). 


PART  IV. 

COURSE  (PROGNOSIS)  AND  THE- 
RAPY OF  THE  PSYCHOSES 


SECTION  I. 

COURSE    (PROGNOSIS)    OF    THE    PSY- 
CHOSES 


Chapter  LXI. 
ONSET  OF  THE  PSYCHOSES. 

From  the  etiological  factors  described  in  the  pre- 
ceding part  the  psychoses  develop  in  two  ways.  The 
onset  of  some  mental  diseases  is  surprisingly  rapid,  in 
others  it  is  gradual  and  imperceptible,  the  cause,  as  a 
rule,  determining  whether  it  is  to  be  precipitous  or  in- 
sidious. 

Rapid  onset  characterizes  the  deliria.  They  appear 
as  soon  as  intoxication  has  taken  place.  Especially  de- 
lirium acutum  (p.  26^),  the  essence  of  which  is  yet 
unexplained,  is  marked  by  a  very  abrupt  onset.  The 
deliria  of  abstinence  (p.  259)  occurring  in  alcoholics, 
morphinists,  etc.,  may  also  begin  suddenly.  When  the 
habitual  stimulant  has  been  withheld  from  the  alcoholic 
for  a  single  day,  delirium  tremens  may  follow  forthwith. 
The  traumatic  psychoses  very  often  set  in  suddenly.  A 
person  falls  out  of  the  window,  loses  consciousness,  re- 
gains it  after  some  time,  and  in  the  course  of  the  same 
day  he  may  manifest  symptoms  of  insanity. 

Much  more  frequent  is  the  slow  development  of  the 
psychoses.  General  paresis  has  a  prodromal  stage  of 
many  months'  duration.  Other  psychoses  are  preceded 
by  a  stage  of  depression  so  commonly  that  some  authors 


124  PSYCHE 

have  sought  to  maintain  that  every  mental  malady  is 
ushered  in  by  a  preliminary  depressive  stage.  But  for 
this  broad  statement  there  is  not  enough  justification,  a 
preliminary  depressive  stage,  although  very  frequent, 
being  absent  in  a  good  many  instances. 

Sometimes  the  psychoses  develop  so  slowly  and  im- 
perceptibly that  the  relatives  of  the  patient  are  unable  to 
determine  the  date  of  the  onset.  The  beginning  of  many 
psychoses  is  so  insidious  that  it  is  overlooked,  and  to  lay- 
men it  appears  as  though  the  attack  had  commenced  all 
of  a  sudden.  But  closer  questioning  reveals  that  the 
patient,  while  yet  sailing  along  under  the  flag  of  health, 
on  occasions  displayed  evidences  of  insanity.  Often  the 
relatives  retrospectively  become  positive  about  the  begin- 
ning of  a  psychosis.  When  unmistakable  signs  of  in- 
sanity appear,  they  comprehend  and  admit  that  the  for- 
mer, more  or  less  noticeable,  changes  in  the  character  of 
the  patient  already  marked  the  beginning  of  his  mental 
malady. 

In  the  psychoses  with  slow  development  the  initial 
symptoms  are  frequently  mistaken  for  the  cause  of  the 
disease.  Thus  in  the  beginning  of  general  paresis  the 
patient  may  exhibit  many  extravagances.  He  spends 
much  money,  drinks  immoderately,  and  commits  other 
excesses.  Through  all  this  he  does  not  arouse  the  sus- 
picion of  neighbors  and  relatives;  for  he  does  not  yet 
talk  "nonsense,"  as  laymen  would  say.  The  disease  then 
progresses  and  becomes  pronounced,  so  that  the  patient  is 
recognized  as  insane  even  by  laymen.  Now  the  cause  of 
the  psychosis  is  attributed  to  the  former  immoderate 
drinking  and  to  the  other  excesses.  And  yet  these  were 
already  the  initial  symptoms  of  the  mental  malady. 

It  is  necessary  to  be  acquainted  with  these  facts  in 


COURSE  OF  THE  PSYCHOSES  125 

order  to  be  able  to  determine  as  nearly  as  possible  the 
beginning  of  a  psychosis.  In  modern  society  the  life  of 
one  man  is  so  intimately  bound  up  with  the  affairs  of 
other  people  that  the  beginning  of  a  psychosis  cannot  be 
regarded  as  something  individual  and  not  affecting 
others.  Often  great  fortunes  are  at  stake,  their  just  dis- 
tribution depending  upon  whether  or  not  it  can  be  proved 
that  at  a  certain  time  their  rightful  owners  were  already 
suffering  from  mental  disorders.  If  a  person  in  the  be- 
ginning of  a  psychosis  has  deeded  away  his  property  to 
strangers  without  the  knowledge  of  his  family,  the  de- 
serving may  be  deprived  of  what  is  their  due,  unless  the 
time  of  onset  of  the  mental  disease  can  be  established.  . 


Chapter  LXII. 
DURATION   OF   THE   PSYCHOSES. 

The  course  of  the  psychoses  also  shows  great  varia- 
bility. There  is  a  rapid  and  a  protracted  course,  and 
there  are  all  possible  forms  intermediary  between  the 
two. 

The  entire  course  of  a  psychosis  may  be  included  in 
a  single  day.  Especially  the  deliria  furnish  many  ex- 
amples of  this  kind.  In  the  so-called  mania  transit oria 
the  patient  is  suddenly  seized  with  a  fit  of  raving  mad- 
ness and  is  well  again  on  the  following  day.  The  whole 
process  usually  terminates  with  the  patient  falling  into  a 
long  sleep  from  which  he  awakes  with  little  recollection 
of  what  has  transpired.  Great  caution  must  be  exer- 
cised in  terming  a  psychosis  mania  transitoria.  This 
diagnosis  is  so  often  unjustifiably  made  that  one  might 


126  PSYCHE 

think  mania  transitoria  were  a  frequent  psychosis,  which 
is  far  from  the  truth.  Mahngerers  may  adduce  this  dis- 
ease as  a  pretext  for  their  misdeeds. 

Psychoses  of  an  abrupt  onset  and  rapid  course 
occur  in  epilepsy.  All  of  a  sudden  the  patient  falls  into 
a  state  of  confusion  and  commits  all  kinds  of  excesses. 
After  several  hours  or  on  the  following  day  his  mind 
is  entirely  clear  again.  The  course  of  such  psychic 
equivalents  of  the  epileptic  attacks  (pp.  243-244)  is  not 
always  so  exceedingly  rapid.  Sometimes  they  last  sev- 
eral weeks,  but  the  short  duration  is  more  frequent. 
Something  similar  is  observed  in  hysteria  in  which  psy- 
choses of  two  or  three  days  duration  occur. 

More  frequent  is  the  slow  course  of  the  mental  dis- 
eases. In  general  the  psychoses  last  for  months,  so  that 
we  cannot  yet  speak  of  a  protracted  course  in  a  mental 
malady  of  several  months'  duration. 

Some  psychoses  are  characterized  by  a  periodic 
course.  Thus  a  patient  enters  the  insane  asylum  with 
the  symptoms  of  acute  mania,  leaves  the  institution  after 
some  time  apparently  cured,  and  returns  after  several 
months  or  a  year  in  a  maniacal  condition.  One  may  be 
inclined  to  speak  of  a  relapse  in  such  a  case;  but  the  ex- 
perienced alienist  will  at  once  think  of  periodicity  of  the 
disease.  And  indeed,  the  patient  having  been  dismissed 
as  cured  for  the  second  time,  comes  back  into  the  asylum 
after  another  interval.  In  such  an  instance  we  are  not 
dealing  with  ordinary  mania  of  comparatively  favorable 
prognosis,  but  with  periodic  insanity  of  incurable  nature. 
Usually  the  mania  is  repeated  until  the  patient  finally 
passes  into  a  state  of  secondary  dementia  (p.  189). 

As  a  rule  the  periodic  course  of  psychoses  is  such 
that  maniacal  stages  alternate  with   free  intervals.     In 


COURSE  OF  THE  PSYCHOSES  127 

some  instances,  however,  it  shows  the  circular  character, 
mania  alternating  with  free  and  melancholic  intervals. 
Psychoses  with  this  cyclic  character  are  also  of  very 
unfavorable  prognosis  (pp.  240-241). 

The  course  of  other  psychoses  is  extremely  long- 
lasting  and  continuous  or  almost  continuous.  Some  pa- 
tients remain  in  the  insane  asylum  for  a  score  of  years 
and  longer. 

Some  psychoses  have  an  irregular  course,  being 
marked  by  exacerbations  and  remissions  of  varying 
duration.  Remissions  are  frequent  in  general  paresis. 
A  common  error  committed  by  the  inexperienced  in  re- 
gard to  general  paresis  is  to  declare  the  patient  as  cured 
in  a  remission.  Not  enough  stress,  therefore,  can  be 
laid  on  the  fact  that  in  the  course  of  general  paresis 
periods  do  occur  during  which  the  patient  appears  en- 
tirely free  from  all  morbid  symptoms.  The  relatives 
of  the  patient  are  easily  misled  by  such  a  remission. 
They  argue  the  patient  is  so  intelligent,  amiable,  speaks 
so  sensibly,  that  <^they  cannot  help  regarding  him  as  en- 
tirely well  again.  He  ought  to  return  home.  They  take 
the  patient  away  from  the  asylum,  convinced  that  the 
psychiatrist  has  this  time  made  a  mistake  in  giving 
originally  a  bad  prognosis  and  in  advising  extreme 
caution  in  the  future.  But  after  a  few  years  they  bring 
the  patient  back  into  the  institution  and  admit  that  their 
medical  adviser  was  right  in  his  statement  that  the  im- 
proved condition  of  the  patient  was  merely  a  remission. 
The  error  of  declaring  a  paretic  as  sane  in  a  remission 
happens  not  only  to  laymen,  but  also  to  physicians.  A 
deficient  pupillary  reaction,  a  weakness  of  the  legs,  a 
disturbance  of  the  handwriting,  an  insignificant  impedi- 
ment of  speech,  may  furnish  a  hint  that  the  patient  is 


128  PSYCHE 

not  entirely  cured,  but  is  in  a  stage  of  remission.  The 
duration  of  these  remissions  is  generally  only  a  few 
months,  but  sometimes  they  may  continue  several  years. 
Something  similar  occurs  in  paranoia.  A  patient  is 
brought  into  the  asylum  suffering  from  delusions  of 
furtherance  and  grievance.  After  some  time  he  ceases 
speaking  about  these  delusions,  and  it  is  hardly  possible 
to  recognize  whether  or  not  he  has  abandoned  them.  His 
behavior  becomes  orderly,  and  he  is  released  from  the 
institution.  After  a  few  years  he  returns  with  new  delu- 
sions or  the  same  ones,  and  it  looks  as  if  the  disease  had 
started  at  the  point  where  it  had  ceased.  The  duration 
of  such  remissions  is  not  always  so  long;  sometimes  the 
disease  becomes  manifest  again  after  a  few  months  with 
the  appearance  of  new  delusions  or  the  recurrence  of  the 
same  ones. 


Chapter  LXHL 
TERMINATION   OF   THE   PSYCHOSES. 

The  psychoses  may  terminate  in  convalescence  fol- 
lowed by  complete  recovery.  When  the  pathological 
process  is  nearing  its  end,  the  morbid  symptoms  grad- 
ually disappear.  The  confusion  ceases,  the  delusions 
are  corrected,  the  restlessness  abates,  the  body  weight  in- 
creases, etc.  The  convalescence  may  pass  into  complete 
recovery  or  the  psychosis  may  be  repeated.  One  of  the 
most  important  means  we  have  at  our  disposal  to  de- 
termine whether  or  not  recovery  has  taken  place,  is  the 
patient's  opinion  about  himself  and  about  those  who  had 
taken  care  of  him  during  his  illness.  When  the  patient 
has  recovered,  he  gains  the  "insight  into  the  disease," 


COURSE  OF  THE  PSYCHOSES  129 

He  recognizes  and  admits  willingly  that  he  was  sick,  that 
the  measures  taken  in  his  case  were  necessary  and  aimed 
at  his  welfare.  He  feels  and  manifests  a  certain  grati- 
tude towards  his  physician  and  his  attendants. 

The  "insight  into  the  disease"  furnishes  the  most 
valuable  criterion  for  recovery.  For  while  the  process 
of  mental  disease  is  still  active,  the  patients  do  not  deem 
themselves  sick,  but  believe  to  be  unworthy,  persecuted, 
nabobs,  powerful  potentates,  proteges  of  kings,  etc.  This 
characteristic  sign  of  complete  recovery  is  especially  of 
great  importance  since  it  renders  possible  the  differentia- 
tion of  a  free  interval  of  periodic  insanity  from  actual 
recovery.  In  such  an  interval  the  patient  has  the  in- 
sight into  the  disease  only  to  a  slight  degree.  He  is 
little  impressed  with,  and  underestimates,  the  impor- 
tance of  his  disease,  arguing  after  this  manner:  'Tt  is 
true,  I  have  been  somewhat  excited  and  feeling  ill  at 
ease,  but  now  I  am  entirely  composed  and  perfectly 
well,  and  it  is  not  at  all  possible  that  I  would  fall 
sick  again."  And  yet  the  fact  that  he  has  gone  through 
the  same  sickness  perhaps  half  a  dozen  times,  and  has 
held  the  same  opinion  after  every  attack,  ought  to  make 
him  consider  the  possibility  of  a  return  of  his  illness.  No 
strong  intellectual  capacity  would  be  required  for  that 
thought.  But  just  this  lack  of  proper  judgment  in  re- 
gard to  his  mental  health  is  a  sign  that  there  is  yet 
some  imperceptible  disorder  in  the  mechanism  of  his 
psychical  functions,  although  to  all  appearances  they  are 
entirely  normal  again.  The  patient  has  a  wrong  opinion 
about  himself,  due  to  a  disturbance  in  the  affective  sphere 
that  still  remains  after  the  disappearance  of  all  the  other 
symptoms  of  mental  disease.  A  morbid  feeling  of  being 
unfailingly  sound  is  still  extant  in  the  patient  and  pre- 


130  PSYCHE  _ 

vents  the  arising  of  any  thought  that  the  condition  of  his 
health  is  apt  to  change  again. 

Some  patients  dismissed  as  convalescent  do  not  gain 
the  full  insight  into  their  disease  before  an  interval  of 
about  half  a  year  has  elapsed.  Then  they  tell  the  physi- 
cian until  this  moment  they  did  not  realize  that  their 
mental  health  was  impaired,  now  they  do  and  at  the  same 
time  they  feel  that  it  has  been  fully  restored ;  now  they  are 
able  to  appear  before  him  without  that  feeling  of  anxiety 
and  fear  which  up  to  that  very  moment  they  still  experi- 
enced in  his  presence. 

There  are  cases,  however,  in  which  the  patients, 
though  entirely  well  again  in  body  and  apparently  also 
in  mind,  do  never  regain  the  insight  into  their  disease. 
In  such  an  instance  the  psychosis  has  terminated  with  a 
certain  mental  defect.  This  represents  the  second  form 
of  the  termination  of  the  psychoses;  the  preceding  acute 
mental  disease  has  brought  about  a  permanent  impair- 
ment of  acuity  of  understanding,  of  warmth  and  mani- 
foldness  of  feeling,  of  nobility  of  character,  etc.  There 
are  numerous  gradations  and  transitions  from  these  slight 
psychical  defects  to  the  mental  states  comprised  in  com- 
plete dementia. 

Fixed  delusions  (Ch.  30,  p.  59)  remaining  after  an 
acute  psychosis  indicate  that  it  has  terminated  in  secon- 
dary mental  weakness.  The  patient  appears  normal 
again,  but  closer  examination  shows  that  he  still  harbors 
erroneous  ideas  on  certain  subjects.  It  is  impossible  to 
convince  the  patient  of  their  absurdity,  and  he  is  unable 
to  abandon  or  correct  these  delusions.  The  preceding 
acute  mental  disorder  has  left  a  permanent  impairment 
of  the  ideational  and  emotional  sphere,  finding  its  ex- 
pression in  these  fixed  delusions.     Although  in  all  other 


COURSE  OF  THE  PSYCHOSES  131 

respects  and  to  all  practical  purposes  the  patient's  mind 
may  be  intact,  healing  with  a  mental  defect  has  taken 
place  in  such  instances. 

Very  frequently  the  mental  defects  remaining  after 
acute  psychoses  are  so  considerable  and  manifold  that 
we  cannot  at  all  speak  of  healing  or  recovery.  In  such 
cases  the  acute  pathological  process  has  resulted  in  sec- 
ondary dementia. 

Some  psychoses  terminate  in  death.  This  does  not 
refer  to  those  cases  in  which  the  exitus  lethalis  was 
brought  about  by  a  misfortune  that  could  have  been  pre- 
vented, for  instance,  by  intentional  suicide  of  the  patient 
or  by  a  fatal  accident.  But  only  those  cases  are  included 
in  this  category  where  death,  as  it  were,  follows  as  a 
natural  consequence  of  the  pathological  process.  Gen- 
eral paresis  ends  in  death,  so  does  delirium  acutum. 


SECTION  II. 
THERAPY    OF    INSANITY 


Chapter  LXIV. 

COMMON      RELUCTANCE     TO     INSTITUTIONAL 

TREATMENT     OF     THE     INSANE;      RESPON= 

SIBILITY  OF  THE   FAMILY  PHYSICIAN. 

The  treatment  of  the  insane  has  made  great  progress 
since  the  age  of  superstition  when  they  were  regarded  as 
mahcious  individuals  possessed  by  the  evil  spirit  and 
eager  for  crime.  They  are  now  universally  recognized 
as  unfortunates  afflicted  with  diseases  of  the  brain.  This 
view  has  become  productive  of  a  more  humane  handling 
of  the  insane.  Modern  psychiatry  may  be  said  to  date 
altogether  from  that  time.  But  even  to  the  present  day 
a  very  considerable  part,  if  not  the  majority,  of  the  in- 
sane of  a  country  are  not  in  public  asylums,  but  under 
inadequate  private  care  or  at  large.  For  in  many  families 
an  aversion  prevails  against  committing  their  insane  pa- 
tients into  an  asylum,  not  because  they  fear  bad  treat- 
ment, but  because  in  a  public  institution  a  case  of  in- 
sanity cannot  be  concealed.  To  divulge  a  case  of  insanity 
is  deemed  injurious  for  social  reasons.  The  importance 
of  hereditary  predisposition  is  not  underestimated,  and 
the  public  knows  the  danger  of  marriage  into  a  family 
with  a  history  of  insanity. 

Because  of  this  common  reluctance  to  institutional 
treatment   of   the   insane   it   devolves   upon   the    family 


THERAPY  OF  INSANITY  133 

physician  to  handle  cases  of  insanity,  and  he  ought, 
therefore,  to  be  acquainted  with  their  treatment.  The 
relatives  of  the  patient  will  say  to  the  family  physician 
they  have  so  much  confidence  in  his  experience  and  skill 
that  for  their  part  he  may  conduct  the  treatment  all  alone 
as  long  as  he  feels  able  to  assume  the  responsibility.  The 
question  is  then  whether  and  how  long  he  shall  take  the 
responsibility  upon  himself.  Evidently  a  maniac  has  to 
be  removed  to  an  asylum  without  much  delay.  But  a 
harmless  patient  suffering  from  secondary  feeble-minded- 
ness  or  an  idiot  may  be  treated  in  his  home.  To  some 
extent  this  holds  good  also  with  the  milder  forms  of 
melancholia.  Little  importance  may  be  attributed  to  the 
suicidal  utterances  of  the  melancholies  in  a  state  of  de- 
pression. But  the  danger  of  suicide  is  very  great  when 
the  depression  is  increased  to  an  emotional  spell  of  an- 
xiety and  fear.  When  such  spells  occur  often,  the 
physician  must  warn  the  relatives  of  the  imminent  dan- 
ger of  suicide  and  emphasize  that  it  can  be  prevented 
only  in  an  institution.  If  they  still  resist  commitment 
to  an  asylum,  he  should  rather  give  up  the  case  than  take 
further  responsibility.  For  when  a  misfortune  does  oc- 
cur, he  will  certainly  receive  the  blame  for  it  and  be 
accused  just  by  those  who  had  assured  him  of  their  un- 
limited confidence  and  had  offered  the  most  emphatic 
resistance  to  sending  the  patient  away  from  the  home. 
The  very  same  people  will  throw  the  first  stone  at  the 
physician  and  will  lay  the  misfortune  at  his  door,  main- 
taining that  he  did  not  insist  sufficiently  upon  removing 
the  patient  to  an  asylum.  After  relinquishing  the  case, 
the  physician  should,  under  certain  conditions,  report  it 
to  the  proper  magistrates  so  that  they  may  prevent  a 
calamity. 


134  PSYCHE  •      , 

Chapter  LXV. 

TRANSPORTING     INSANE    PATIENTS    TO    THE 
ASYLUM. 

When  the  relatives  of  an  insane  patient  have  de- 
cided to  place  him  into  an  asylum,  the  physician  must 
help  them  with  his  advice  and  supervise  the  transporta- 
tion. As  a  rule  force  has  to  be  used,  for  the  removal 
from  the  home  must  usually  be  carried  out  against  the 
will  of  the  patient.  Certain  conditions  are,  therefore,  to 
be  fulfilled.  First  of  all  somebody  must  be  present  who 
has  the  right  to  transfer  the  patient  to  an  asylum  against 
his  will.  Some  patients,  even  after  their  recovery,  bear 
a  grudge  against  those  who  had  deprived  them  of  their 
liberty.  They  even  harass  them  with  legal  proceedings 
on  that  account.  It  is,  therefore,  advisable  for  the  physi- 
cian to  be  well  informed  about  the  relatives'  right  to  com- 
mit the  patient  to  an  asylum.  There  can  be  no  doubt 
about  the  right  of  a  husband  to  place  his  legally  insane 
wife  into  an  asylum,  and  conversely.  The  same  right 
appertains  to  the  parents  towards  their  children  under 
age.  But  it  may  be  doubted  whether  brothers  and  sisters 
have  that  right  towards  each  other.  With  paretics  or 
with  patients  suffering  from  secondary  dementia  it  will 
not  be  difficult  to  come  to  a  decision  regarding  the  right 
of  commitment,  since  their  future  resentment  for  re- 
straint of  their  liberty  may  be  dismissed  because  of  the 
incurability  of  the  disease. 

Frequently  when  a  patient  is  violent  and  offers  re- 
sistance to  the  removal  from  home,  the  request  is  made 
by  the  relatives  that  no  force  be  used,  that  the  physician 
should,  in  some  way,  lure  the  patient  into  the  institution 
without  arousing  his  suspicion.     In  some  instances  this 


THERAPY  OF  INSANITY  135 

can  be  accomplished  without  difficulty,  as  with  paretics 
in  a  maniacal  stage.  But  if  the  patient  is  intelligent 
enough  to  recognize  the  purpose  of  the  journey,  ruse 
should  not  be  resorted  to.  For  he  is  likely  to  find  it  out, 
and  then  he  may  become  violent  and  perhaps  escape. 
Now,  in  a  case  where  deception  is  contraindicated  there 
remains  nothing  else  but  to  tell  the  patient  openly  that 
he  must  go  to  a  hospital  whether  he  wants  it  or  not.  Be- 
fore communicating  this  to  him  certain  measures  must 
be  prepared.  All  dangerous  implements  must  be  re- 
moved and  windows  and  doors  secured  so  as  to  render 
escape  impossible.  The  physician  must  surround  him- 
self with  a  sufficient  number  of  attendants  to  prevent  any 
violent  act  of  the  patient  either  against  himself  or 
against  others. 

If  necessary,  the  physician  should  not  hesitate  to 
make  use  of  the  strait- jadcet  during  the  transport.  With 
this  implement  two  attendants  can  accomplish  the  de- 
sired end,  while  otherwise  four  would  hardly  suffice. 
Without  the  strait- jacket  it  is  sometimes  necessary  to 
shackle  the  patient.  This,  on  one  hand,  is  very  disagree- 
able to  the  patient  and,  on  the  other  hand,  is  not  without 
danger.  At  the  place  where  the  shackles  press  the  skin 
gangrene  may  be  produced  because  the  patient  does  not 
try  to  avoid  the  pressure  (Ch.  50,  p.  98). 

The  ordinary  strait- jacket  is  a  coat  reaching  down 
below  the  hips,  closing  in  the  back,  and  provided  with 
long  sleeves  to  the  anterior  ends  of  which  are  attached 
strong  leather  straps.  The  jacket  is  put  on  in  the  fol- 
lowing way:  An  attendant  sticks  his  left  hand  into  the 
right  sleeve,  through  its  anterior  end,  and  his  right  hand 
into  the  left  sleeve,  and  shoves  the  sleeves  over  his  arms 
vmtil  the  hands  come  out  through  the  posterior  openings. 


136  PSYCHE 

Now  he  approaches  the  patient  who  is  held  on  both  sides, 
grasps  one  wrist,  and  shoves  the  sleeve  over  the  patient's 
arm.  The  same  is  done  with  the  other  wrist  and  arm. 
The  arms  are  then  crossed  and  the  straps  brought  to- 
gether on  the  back  and  tied.  In  this  way  three  attendants 
are  usually  able  to  master  any  patient  even  if  he  resists 
and  struggles.  There  are  patients,  however,  who  can 
not  be  put  into  the  strait-jacket  even  with  the  greatest 
of  efforts.  In  such  cases  there  remains  nothing  else  ex- 
cept to  apply  a  general  anaesthetic.  For  after  the  physi- 
cian has  once  resorted  to  force,  he  ought  not  to  withdraw 
under  any  circumstances  without  having  attained  the  de- 
sired end.  Deep  narcosis  is  not  necessary.  The  more 
the  patient  struggles,  the  stronger  he  inhales  the  anaes- 
thetic and  the  sooner  he  becomes  unconscious. 

When  a  violent  patient  in  a  strait- jacket  is  to  be 
brought  into  the  carriage,  it  is  advisable  to  put  a  cloak 
around  him  to  spare  the  public  the  disgusting  sight  of 
the  strait- jacket.  In  the  city  the  police  authorities  ought 
to  be  informed  that  a  violent  insane  patient  is  to  be  trans- 
ported somewhere,  otherwise  when  the  patient  becomes 
turbulent  and  vociferous,  a  tumult  may  arise  and  an 
unfortunate  incident  occur. 

When  an  insane  patient  is  to  be  transported  to  the 
asylum  by  rail,  he  must  be  brought  to  the  station  and  into 
the  car  before  the  other  traveling  public  arrives.  The 
railroad  administration  must  be  notified  beforehand  of 
his  transportation.  If  the  patient  is  violent  or  has  uttered 
the  slightest  suicidal  intentions,  two  attendants  must 
guard  the  windows  near  him.  He  must  not  be  per- 
mitted to  be  alone  for  a  moment.  At  least  one  female 
nurse  should  accompany  a  female  patient. 

It  is  very  difficult  to  master  a  violent  patient  who 


THERAPY  OF  INSANITY  137 

threatens  to  make  use  of  a  weapon  if  anyone  should 
approach  him.  Nothing  can  be  accomplished  in  such 
an  instance  with  mere  force,  but  some  artifice  is  to  be 
resorted  to.  The  physician  must  see  to  it  that  some  re- 
liable person  be  in  the  room  with  the  patient.  It  will 
scarcely  be  the  case  that  he  will  not  permit  anyone  what- 
soever to  be  near  him.  While  this  person  tries  to  occupy 
the  patient's  mind,  the  physician,  at  a  favorable  moment, 
enters  the  room  with  several  attendants,  thus  surprising 
the  patient  with  superior  force.  Two  of  the  attendants 
must  have  been  instructed  beforehand  not  to  wait  for 
any  further  orders,  but  to  get  at  once  behind  the  patient, 
one  at  each  side.  The  physician  steps  in  front  of  the 
patient  and  begins  to  divert  his  attention.  At  this  mo- 
ment he  is  grasped  at  each  arm  by  the  attendants  in  back 
of  him.  Immediately  all  his  pockets  are  thoroughly 
searched  and  all  dangerous  implements  taken  away.  It 
is  altogether  a  strict  rule  not  to  commence  the  transport 
to  the  asylum  of  any  insane  patient  without  searching 
him  for  dangerous  instruments. 

Even  harmless  patients,  from  the  time  they  have 
found  out  that  they  are  to  be  transferred  to  the  insane 
asylum,  must  never  be  left  alone  for  a  moment. 

During  the  transport  no  utterance  whatsoever  con- 
cerning the  insane  asylum  or  the  treatment  should  be 
made  in  the  presence  of  the  patient. 


Chapter  LXVI. 
INSANE  ASYLUM. 

The  objection  has  been  raised  against  institutional 
treatment  of  the  insane  that  their  disease  may  become 
aggravated  when  they  are  surrounded  by  unfortunates 


13B  PSYCHE 

like  themselves  and  see  their  pitiable  plight,  thereby  more 
readily  comprehending  their  own  misfortune.  This  dis- 
advantage has  to  be  put  up  with  as  it  can  hardly  be 
avoided,  especially  with  patients  in  ordinary  financial  cir- 
cumstances. On  the  other  hand,  the  disadvantage  is 
outweighed  by  the  benefits  arising  from  treatment  away 
from  home.  As  in  other  nervous  diseases  so  also  in  psy- 
choses it  is  best  for  the  patient  to  be  taken  away  from 
the  conditions  and  the  environment  in  which  he  has  been 
living  up  to  that  time.  This  advant^ige  is  most  easily 
obtained  by  removal  of  the  patient  into  an  institution. 
The  chief  benefit  of  asylum,  treatment,  however,  consists 
in  the  patient  being  withdrawn  from,  and  protected 
against,  many  dangers  hardly  avoidable  while  he  is  un- 
der care  in  his  own  home,  such  as  refusal  of  food, 
attempt  at  escape  or  at  suicide,  etc. 

The  principles  to  be  followed  in  the  insane  asylum 
must  be  purely  medical,  i.  e.,  the  insane  are  to  be  treated 
as  patients.  They  must  share  the  benefits  that  have 
accrued  from  the  progress  of  science  for  all  those 
afflicted  with  disease.  All  hygienic  requirements  must 
be  fulfilled  in  the  asylum.  It  must  have  a  good  situation, 
good  ventilation,  good  air,  good  light,  good  water  sup- 
ply, and  good  regulation  of  the  temperature  of  the  rooms. 
Furthermore,  there  must  be  different  departments  in  the 
institution.  Aside  from  the  separation  into  a  male  and 
a  female  division  there  must  be  different  wards  accord- 
ing to  the  different  ways  the  patients  conduct  themselves. 
In  one  department  are  placed  quiet  patients  not  needing 
extraordinary  watching,  in  another  one  patients  who  are 
very  restless,  again  in  another  one  patients  who  do  not 
keep  themselves  clean,  etc.  A  separate  department  is  to 
be  fitted  up  for  patients  who  would  use  any  object  as  a 


THERAPY  OF  INSANITY  139 

weapon  against  themselves  and  others.  Here  everything 
must  be  clinched  and  riveted.  It  must  be  impossible  to 
move  chairs,  to  upset  tables,  etc.  Further,  there  must  be 
special  wards  for  patients  needing  extraordinary  watch- 
ing. Into  these  wards  are  put  also  those  patients  who 
have  just  entered  the  institution,  and  whose  conduct  has 
first  to  be  determined  before  bringing  them  into  the 
wards  adapted  for  them.  Moreover,  the  social  circum- 
stances of  the  patients  are  to  be  taken  into  consideration 
in  establishing  an  asylum  for  the  insane. 

An  insane  asylum  should  be  constructed  to  accom- 
modate no  more  than  500  patients  in  order  that  one 
physician  may  be  able  to  superintend  it,  which  is  a  very 
important  point  for  the  successful  work  of  the  institu- 
tion. Since  many  patients  can  and  ought  to  be  occupied, 
sufficient  gardens  must  be  provided.  There  are  several 
systems  of  insane  asylums.  In  the  closed  institutions 
the  various  buildings  are  connected,  in  the  pavilion  sys- 
tem they  are  separated,  and  in  the  agricultural  institutions 
special  provisions  are  made  for  an  agricultural  occupa- 
tion of  the  patients.  The  first  system  is  best  adapted  for 
the  neighborhood  of  big  cities  because  of  the  saving  of 
ground  and  because  of  the  easy  frustration  of  attempts 
at  escape.  Even  these  closed  institutions  must  have 
enough  garden  grounds.  The  pavilion  system  is  appro- 
priate for  country  sanitaria.  It  has  this  disadvantage 
that  the  physician  cannot  easily  overlook  everything  and 
cannot  come  unseen  into  the  different  departments.  The 
agricultural  institutions  offer  the  best  advantages  with 
respect  to  the  occupation  of  the  patients  and  with  respect 
to  the  prevention  of  certain  diseases  so  frequent  in  the 
closed  institutions,  as  tuberculosis.  They  are  naturally 
adapted  only  for  the  country.     If  it  is  possible  to  erect 


I40  PSYCHE 

several  insane  asylums  in  a  district,  it  is  advisable  to 
make  use  of  more  than  one  system. 

One  person,  and  that  a  physician,  is  to  be  vested 
with  supreme  authority  in  the  asylum,  all  other  officials 
should  be  subordinate  to  him.  If  they  are  coordinate,  a 
dualism  reigns  in  the  institution  which  cannot  fail  to  be 
prejudicial. 

A  reliable  staff  of  nurses  is  indispensable  for  an 
insane  asylum.  They  must  be  obedient,  consciencious, 
must  have  entered  into  hospital  service  in  early  years, 
and  must  follow  their  occupation  with  a  certain  love  and 
devotion,  being  content  with  the  disagreeable  sides  and 
arduous  tasks  of  the  care  of  the  sick.  Since  stability  of 
the  nurses'  staff  is  a  great  requisite,  it  should  consist  only 
of  people  who  have  made  the  care  of  the  sick  their  call- 
ing in  life  and,  therefore,  remain  in  the  asylum  perma- 
nently. All  this  can  be  attained  only  by  giving  the  nurses 
ample  pecuniary  compensation  and  assurance  of  a  suffi- 
cient pension  after  a  faithful  service  of  a  number  of 
years.  The  nurses  should  receive  regular  instruction. 
If  after  one  year's  service  a  nurse  proves  not  to  possess 
the  proper  qualification  for  his  position,  he  is  to  be  dis- 
missed. 

A  staff  of  competent  assistant  physicians  is  very 
requisite.  For  every  hundred  patients  there  ought  to  be 
at  least  one  assistant. 

In  the  treatment  of  the  patients  mechanical  com- 
pulsion is  to  be  restricted  to  the  most  desperate  cases. 
Care  must  be  taken  that  patients  with  destructive  ten- 
dencies may  not  harm  themselves,  that  the  institution 
be  provided  with  clothes  difficult  to  tear,  that  there  be 
enough  space  in  the  wards  so  that  the  patients  need  not 
lie  close  to  each  other,  that  there  be  enough  room  for 


THERAPY  OF  INSANITY  141 

isolation  and  a  sufficient  number  of  attendants.  Only 
then  the  strait- jacket  may  be  dispensed  with.  Sometimes, 
however,  it  is  absolutely  necessary,  as  in  surgical  cases. 
A  violent  patient  with  a  fracture  of  the  leg  must  even  be 
chained  to  the  bed. 

The  general  treatment  must  be  humane.  The  at- 
tending physician  should  not  excite  the  patient  by  his 
visit.  In  refusing  unjustified  wishes  of  the  patient  he 
should  act  in  a  manner  that  will  not  hurt  his  feelings. 
He  should  never  make  the  patient  feel  his  superiority, 
and  should  never  bear  a  grudge  against  a  patient  for  dis- 
respect or  ill  behavior.  To  fulfill  all  this  is  not  at  all 
easy  and  has  to  be  learned  by  experience. 

Mechanical  compulsion  in  the  treatment  of  insane 
patients  in  the  past  may  be  excused  when  one  bears  in 
mind  the  insufficient  means  then  at  the  disposal  of  the 
institutions. 


Chapter  LXVII. 

TREATMENT    OF    THE    INDIVIDUAL    SYMPTOMS 
OF  INSANITY. 

Morbid  Mood.  A  patient  laboring  under  morbid 
depression  must  be  left  alone.  All  efforts  to  cheer  him 
up,  to  make  him  participate  in  entertainments  and  pleas- 
ures are  anything  but  conducive  of  good.  They  do  not 
mitigate  the  depression,  but  rather  augment  it  (p.  32). 
If  the  patient  complains  about  uneasiness  and  anxiety,  a 
few  comforting  words  may  be  said  to  him,  but  nothing 
more  should  be  done. 

Likewise  in  morbid  exaltation  it  is  entirely  wrong 
to  attempt  to  depress  the  mood  of  the  patient  artificially. 


142  PSYCHE 

At  best  an  outburst  of  anger  is  produced  (p.  35).  The 
patient  must  not  be  directly  contradicted;  on  the  other 
hand,  it  is  not  necessary  to  yield  to  all  his  whims.  To 
refuse  the  wishes  of  maniacal  patients  without  direct 
contradiction  the  peculiar  ^'tractability"  of  the  maniacs 
is  resorted  to  with  great  advantage  (pp.  86,  167,  169). 

Delusions.  The  management  of  delusions  is  sim- 
ilar to  that  of  morbid  mood.  Laymen  often  think  they 
can  be  overcome  without  difficulty.  When,  for  instance, 
a  patient  wails  about  the  death  of  a  dear  friend,  who  is 
still  living,  it  is  very  easy,  according  to  laymen's  notions, 
to  do  away  with  this  delusion  by  bringing  the  friend  face 
to  face  with  the  patient.  But  the  delusion  will  persist 
nevertheless.  The  patient  will  now  complain  just  this 
is  his  great  misfortune  that  some  scoundrel  tries  to  per- 
sonify his  dear  friend.  There  remains,  therefore,  noth- 
ing else  to  do  but  to  try  to  allay  somewhat  the  delusion, 
e.  g.,  to  say  to  the  patient  he  is  sick  now,  when  he  will 
be  well  again,  everything  will  be  in  perfect  order. 

Formerly  the  attempt  was  sometimes  made  to  sup- 
press delusions  of  grandeur  forcibly  by  cold  douches  and 
other  such  harsh  measures.  But  nothing  was  gained 
thereby  except  that  the  patient  now  simulated,  not  dar- 
ing to  give  expression  to  his  delusions  which  he  still  har- 
bored just  as  strongly  as  before. 

Morbid  Activity  of  the  Will.  Some  patients 
carry  out  so  few  volitional  movements  that  they  are  un- 
able even  to  take  food  handed  to  them.  Such  patients 
must  not  be  left  sitting  or  lying,  motionless  for  hours  and 
days,  but  psychical  and  mechanical  stimuli  must  be  em- 
ployed. Usually  little  is  attained  by  the  former.  To 
admonish  a  stuporous  patient  to  move  about  is  like  tell- 
ing a  person  with  fractures  of  both  legs  to  walk.    Words 


THERAPY  OF  INSANITY  143 

are  futile  in  such  cases,  but  other  effective  measures  must 
be  used,  such  as  massage  and  passive  exercises. 

The  management  of  patients  controlled  by  irresist- 
ible motor  impulses  and  intent  upon  destroying  every- 
thing within  reach  is  very  difficult.  It  is  evident  that 
they  cannot  be  permitted  to  do  as  they  please.  Formerly 
they  were  restrained  mechanically  by  means  of  the  strait- 
jacket.  Nowadays  the  treatment  is  not  so  harsh.  In 
the  favorable  season  of  the  year  they  may  be  permitted 
to  move  about  in  the  open  air.  When  the  weather  is  too 
cold  or  too  hot,  or  otherwise  unfavorable  to  keep  them 
out  of  doors,  they  must  be  isolated.  To  preclude  tear- 
ing of  the  clothes,  they  are  made  of  firm  material,  as 
English  leather,  which  is  also  washable.  For  patients 
of  great  strength  still  stronger  material,  as  sailing 
canvass,  must  be  used.  To  prevent  the  patients  from 
undressing  themselves,  buttons  have  been  constructed 
which  they  can  neither  open  nor  tear  off.  The  manu- 
facture of  foot-wear  adapted  for  such  patients  also  offers 
great  difficulties. 

Refusal  of  Food.  Some  patients  refuse  to  take 
nourishment.  If  the  reason  for  this  is  a  diminution  of 
the  volitional  activity  to  such  an  extent  that  the  patients 
are  unable  to  carry  out  any  movement  whatsoever,  as  in 
stupor,  artificial  feeding  ought  not  to  be  deferred  very 
long.  It  should  be  begun  early  and  not  postponed  until 
the  patients  are  nearly  exhausted  through  starvation. 
But  with  melancholies  who  think  themselves  unworthy 
of  nourishment,  or  with  patients  who  imagine  their  food 
to  be  poisoned,  artificial  feeding  may  be  deferred  for 
some  time,  especially  since  by  means  of  certain  devices 
the  patients  can  be  induced  to  take  some  food.  Such 
patients,  without  being  malingerers,  eat  in  secret  when- 


144  PSYCHE 

ever  possible.  Melancholies  declining  to  take  food  on 
account  of  delusions  of  self -depreciation  eat  something 
that  appears  discarded,  believing  it  to  be  of  no  use  for 
anyone  more  worthy  of  nourishment  than  they  are. 
They  do  not  take  food  handed  to  them  in  the  proper 
manner,  but  they  consume  that  which  has  been  left  over 
by  others.  Eating  secretly  is,  therefore,  not  incompati- 
ble with  delusions  which  entail  refusal  of  food.  Patients 
afraid  of  poison  eat  food  destined  for  others.  The  re- 
sistance to  taking  nourishment  may  sometimes  be  over- 
come by  offering  to  the  patients  their  favorite  dishes. 
There  remain,  however,  some  patients  who,  induced  by 
delusions,  would  rather  starve  to  death  than  take  food. 
In  such  cases  artificial  feeding  should  be  delayed  for  a 
while,  but  as  soon  as  the  slightest  symptoms  of  inanition 
appear,  it  must  be  carried  out  by  means  of  the  stomach 
tube  introduced  through  the  mouth  or  the  nose. 

Insomnia.  Almost  every  patient  in  the  initial  stage 
of  a  psychosis  suffers  from  sleeplessness.  It  can  be  com- 
bated by  drugs,  but  they  are  injurious.  The  assertion 
may  unreservedly  be  made  that  recovery  from  a  psy- 
chosis ensues  so  much  sooner,  the  less  hypnotics  have 
been  used.  For  this  reason  insomnia  ought  not  to  be 
treated  directly,  for  a  time  at  least.  But  when  the 
strength  of  the  patient  does  not  suffice  to  stand  the  ex- 
hausting effects  of  sleeplessness,  hypnotics  are  indicated. 
An  effective  remedy  is  chloral  hydrate.  It  should  not 
be  given  in  larger  doses  than  two  grams.  It  must  be 
employed  with  great  caution  in  the  old  and  in  those 
affected  with  heart  disease.  Patients  who  refuse  to  take 
any  internal  remedy  may  be  given  morphine  hypoder- 
mically.     A  convenient  hypnotic,   free   from  danger,  is 


THERAPY  OF  INSANITY  145 

paraldehyde  which  may  be  given  in  doses  of  5  to  6  grams. 
Sulfonal  is  dangerous  and  of  Httle  effect. 

Suicide.  Special  attention  must  be  paid  to  the  sui- 
cidal inclinations  of  the  insane.  To  prevent  suicide  the 
windows  of  the  wards  must  be  secured  by  gratings  with 
interspaces  not  wider  than  the  smallest  diameter  of  the 
skull  of  an  adult.  Constant  watching  is  necessary.  In 
the  night  several  watchers  should  alternate.  They 
should  be  kept  under  strict  supervision  by  a  night  watch- 
man's apparatus  furnished  with  all  possible  safeguards 
against  deception. 

In  suicidal  attempts  cutting  and  stabbing  instru- 
ments are  not  the  most  dangerous.  Much  more  to  be 
feared  is  the  attempt  at  hanging.  It  can  be  carried  out 
on  any  door  latch,  on  any  nail  in  the  wall.  A  noose  is 
easily  made  out  of  a  towel  or  handkerchief.  Death  fol- 
lows quite  rapidly.  After  cutting  or  stabbing,  however, 
the  patients  can  often  be  saved  even  after  a  considerable 
interval.  Very  dangerous  is  also  the  attempt  at  strangu- 
lation, the  patient  constricting  his  throat  with  a  cloth. 
The  rattling  noise  in  the  respiratory  tract,  commencing 
with  the  ensuing  dyspnoea,  may  be  heard  and  attract  the 
attention  of  the  attendants.  Sometimes  the  patient's  life 
is  saved  by  a  relaxing  of  the  pressure  of  the  cloth  when 
his  strength  begins  to  fail.  He  may  elude  this  by  mak- 
ing a  knot  and  pulling  it  through  a  loop  whereby  a  loos- 
ening of  the  improvised  string  is  prevented.  He  then 
loses  consciousness  after  a  short  time  and  death  follows 
rapidly.  All  these  suicidal  attempts  can  be  frustrated 
only  by  constant  and  careful  watching. 

Deficient  Deglutition.  Especially  in  paretics 
deglutition  is  often  impaired.  They  cannot  swallow  the 
food  properly  and  aspirate  something  of  it  into  the  larynx 


146  PSYCHE 

or  trachea.  Such  an  incident  requires  immediate  help  be- 
cause of  the  danger  of  suffocation.  The  physician  hur- 
riedly called  to  a  case  of  foreign  body  in  the  respira- 
tory tract  may  find  the  patient  already  unconscious, 
cyanotic,  pulseless.  He  must  at  once  examine  the  air 
passages.  As  soon  as  he  succeeds  to  remove  the  foreign 
body,  life  may  return.  There  is  hope  of  saving  the  pa- 
tient's life  as  long  as  he  is  still  cyanotic,  and  the  lower 
jaw  is  still  firmly  pressed  against  the  upper  one.  The 
greater  the  difficulty  of  removing  the  jaws  from  one  an- 
other, the  more  there  is  prospect  of  restoring  the  life  of 
the  patient.  For  shortly  before  death  the  jaws  are 
tightly  closed.  Soon  after  death  they  become  relaxed. 
Much  later,  when  rigor  mortis  has  set  in,  the  maxillary 
muscles  become  again  contracted.  The  physician  must 
force  apart  the  jaws  and  reach  down  into  the  air  pas- 
sages as  far  as  the  vocal  cords.  Sometimes  the  foreign 
body  remains  sticking  in  the  oesophagus.  H  this  be  the 
case,  the  foreign  body  must  be  pushed  down  further  into 
the  stomach.  Besides,  the  danger  caused  by  a  foreign 
body  in  the  oesophagus  is  not  very  great.  At  any  rate 
the  physician  must  preserve  his  presence  of  mind  and  act 
decidedly  and  quickly. 

A  patient  may  swallow  something  that  injures  the 
oesophagus,  for  instance,  a  rough  stone.  As  a  conse- 
quence food  is  regurgitated,  although  the  foreign  body 
is  not  wedged  any  more  in  the  oesophagus.  An  oeso- 
phageal sound  must  be  passed,  li  no  resistance  is  en- 
countered, the  regurgitation,  sometimes  persisting  for 
several  days,  is  merely  caused  by  the  wound  in  the  oeso- 
phageal mucous  membrane. 

Wounds  of  the  Skin.  Phlegmons,  erysipelas,  decu- 
bitus, etc.,  must  be  prevented  by  paying  careful  attention 


THERAPY  OF  INSANITY  147 

to  the  slightest  lesions  of  the  skin,   especially  in  such 
patients  who  are  inclined  to  injure  themselves. 


Chapter  LXVIII. 
HYPNOTISM   IN  THE  TREATMENT  OF  INSANITY. 

Hypnotism  is  founded  on  suggestion,  i.  e.,  on  the 
possibility  of  introducing  ideas  from  an  outer  source  into 
the  train  of  thoughts  of  the  hypnotizable  subject.  Sug- 
gestion plays  an  important  part  in  many  affairs.  The 
art  of  persuasion  is  based  on  suggestion.  In  instruction 
and  education  suggestion  is  made  use  of  in  manifold 
ways.  Since  hypnotism  has  been  recognized  to  depend 
merely  on  suggestion,  the  former  artifices  of  producing 
the  hypnotic  sleep,  as  by  stroking  or  by  making  the  sub- 
ject stare  unremittingly  at  a  brilliant  object,  etc.,  have 
been  abandoned.  The  hypnotic  sleep  can  be  brought 
about  simply  by  telling  the  individual  to  be  hypno- 
tized that  he  will  soon  fall  asleep.  The  hypnotic  sleep, 
no  matter  in  which  way  produced,  renders  suggestion 
still  more  easy.  Great  hopes  had  been  built  upon  hyp- 
notism in  the  treatment  of  the  insane.  Unfortunately 
the  results  of  hypnotic  treatment  of  insanity  have  proved 
disappointing.  Delusions,  feelings  of  anxiety,  depres- 
sion, refusal  of  food,  morbid  volitional  activity,  etc.,  are 
not  influenced  by  hypnotism'. 


PART   V 

SPECIAL    PATHOLOGY    OF 
INSANITY 


Chapter  LXIX. 

CLASSIFICATION    OF    THE    PSYCHOSES. 

In  the  classification  of  the  psychoses  pathologic 
anatomy  does  not  offer  any  clue  to  be  followed.  For 
very  little  is  known  of  the  pathologic  anatomy  of  in- 
sanity. To  arrange  the  manifold  and  intricate  pictures 
under  which  the  psychoses  present  themselves  into  a 
somewhat  practicable  system  only  the  symptoms  and 
etiology  of  insanity  are  available.  With  regard  to  the 
symptoms  two  classes  of  clinical  entities  of  insanity  may 
be  distinguished. 

I.  Mental  disease  commencing  after  the  early 
stages  of  the  general  development  of  the  organism,  the 
patient  having  been  sound  in  foetal  life  and  in  early 
childhhod. 

II.  Mental  diseases  dating  from  earliest  childhood 
and  attributable  to  arrest  of  development  or  to  other 
disturbances  in  foetal  life  or  in  early  childhood. 

To  the  first  class  belong  the  following  clinical  pic- 
tures : 

1.  Melancholia  and  Stupor. 

2.  Mania. 

3.  Hallucinatory  Insanity. 

4.  Primary  Insanity  or  Paranoia. 

5.  Secondary  Insanity. 

6.  Delirium. 

7.  Secondary  Dementia,  Secondary  Feebleminded- 
ness. 


152 


PSYCHE 


8.  Primary  Mental  Weakness,  Primary  Curable 
Dementia. 

The  second  class  comprises  the  following  psychoses : 

1.  Idiocy. 

2.  Cretinism. 

Idiocy  appears  in  severe  and  mild  forms.  The  latter 
may  be  designated  as  imbecility. 

Certain  forms  of  one-sided  mental  weakness  are  in- 
cluded in  imbecility : 

a.  Moral  Insanity,  Moral  Idiocy. 

b.  Querulous  Insanity,  Morbid  Litigiousness. 

c.  Originary  Insanity. 

d.  Contrary  Sexual  Feeling. 

Considering  the  insane  diatheses  and  etiology  we 
may  distinguish  the  following  forms  of  insanity : 

I.  Hereditary  Predisposition  to  Insanity,  Hered- 
itary Insanity, 

Hysterical  Insanity. 

Phrenasthenia,  Psychasthenia, 

Dementia  Praecox, 

Recurrent  Insanity,  Manic-depressive  Insanity. 

Epileptic  Insanity, 

Insanity  of  General  Paresis, 

Toxic  Insanity,  Alcoholic  Insanity, 

Traumatic  Insanity, 

Insanity  in  Organic  Brain  Diseases. 

Delirium  Acutum. 

Senile  Insanity. 
There  are   many  other   classifications   of   insanity, 
but  no  one  has  received  general  acceptance. 


9 

lO 

II 

12 


SPECIAL  PATHOLOGY  153 

Chapter  LXX. 
PSYCHOSES  AND  AGE  OF  PATIENT. 

Certain  psychoses  occur  most  frequently  at  a  certain 
period  of  life.  Cretinism  and  idiocy  are  observed  chiefly 
in  childhood.  Being  permanent  states  they  persist  also  in 
adult  life.  Phrenasthenia,  hysterical  insanity,  dementia 
praecox,  recurrent  insanity  prevail  at  the  periods  of 
puberty  and  adolescence.  In  the  age  of  maturity  all 
forms  of  insanity  are  met  with,  particularly  paranoia, 
general  paresis,  traumatic  and  toxic  insanities.  In  and 
after  the  climacterium  melancholia  is  very  frequent,  and 
senile  insanity  belongs  to  old  age. 


SECTION  I. 

MENTAL  DISEASES  COMMENCING  AFTER 

THE  EARLY  STAGES  OF  THE  GENERAL 

DEVELOPMENT  OF  THE  ORGANISM 


Chapter  LXXI. 
MELANCHOLIA. 

Symptom-complex.  A  characteristic  complex  of 
symptoms  constitutes  the  cHnical  picture  of  melanchoHa 
which  is  based  on  different  causes,  as  intoxication,  gen- 
eral paresis,  senility,  etc.  Its  chief  features  are  the  fol- 
lowing: The  mood  is  morbidly  depressed.  The  idea- 
tional process  is  retarded,  the  memory  weakened.  The 
patient  labors  under  delusions  of  self-depreciation 
(p.  57),  and  has  sometimes  hallucinations  and  illusions. 
The  frequency  of  the  volitional  manifestations  is  dimin- 
ished, the  energy  lessened.  The  vegetative  processes  are 
reduced.  Sometimes  the  patient  is  suddenly  seized  with 
attacks  of  anxiety  and  fear.  During  such  spells  the  pic- 
ture is  somewhat  different  from  the  one  just  sketched; 
the  energy,  for  instance,  is  greatly  increased  (pp.  2^^,  34). 

Clinical  Picture.  The  patient  has  a  sad  expression 
on  his  countenance  and  complains  of  feeling  ill  at  ease. 
He  believes  to  be  irretrievably  lost  in  this  world  as  well 
as  in  the  hereafter.  He  wishes  for  his  death,  but  not  as 
a  salvation;  for  he  thinks  everlasting  perdition  is  allotted 
to  him.  Sometimes  this  depressive  state  becomes  in- 
creased to  an  intense  emotion  of  anxiety  and  fear.     The 


SPECIAL  PATHOLOGY  155 

energy  is  then  augmented.  The  patient  runs  about,  rest- 
less and  agitated,  cries  and  laments  aloud,  unwilling  to 
listen  to  any  words  of  appeasement  and  consolation — 
melancholia  agitata.  That  the  depression  of  mood,  the 
most  important  and  most  conspicuous  symptom  of  melan- 
choilia,  is  of  morbid  nature  can  easily  be  recognized.  It 
cannot  be  influenced  in  the  least  by  persuasion  and  con- 
solation, the  reasons  adduced  by  the  patient  to  explain 
it  are  entirely  insufficient,  and  time  has  no  mitigating 
effect  on  it  so  that  it  persists  with  undiminished  intensity 
for  weeks  and  months  (Ch.  13,  p.  31). 

The  ideational  process  is  markedly  retarded.  It  is 
laborious  for  the  patient  to  answer  simple  questions.  He 
is  himself  conscious  of  the  great  poverty  of  his  ideas  and 
of  the  impairment  of  his  memory.  Fluctuations  occur 
in  this  condition  in  the  course  of  the  same  day  so  that  the 
memory  is  less  affected  at  some  hours  than  at  others. 

The  delusions  of  the  melancholic  patient  are  quite 
characteristic.  He  imagines  himself  to  be  despised,  exe- 
crated, persecuted,  and  often  gives  utterance  to  his  im- 
agination. For  the  correct  interpretation  of  these  delu- 
sions we  must  bear  in  mind  that  the  patient  himself 
believes  to  deserve  the  contempt  and  persecution  he  main- 
tains to  be  exposed  to,  that  his  self  plays  a  role  laden 
with  guilt  and  sin  (Ch.  28,  p.  57).  He  tries  to  explain 
his  delusions  by  some  reason  or  other.  Hallucinations 
and  illusions  in  several  senses  help  to  strengthen  the  delu- 
sions, but  in  the  main  the  latter  are  the  outcome  of  the 
morbid  mood. 

The  frequency  of  the  volitional  manifestations  is 
diminished  when  attacks  of  anxiety  and  fear  are  not 
present.  The  patient  is  quiet,  speaks  seldom,  slowly,  and 
with  a  low  voice,  makes  but  hesitating  movements  with 


156  PSYCHE 

little  expense  of  power.  His  energy  is  lessened.  He  does 
not  make  an  effort  to  move  from  his  place,  not  even  to 
relieve  nature,  and  takes  no  nourishment  or  eats  but 
slowly  and  reluctantly.  In  an  attack  of  anxiety,  how- 
ever, the  energy  may  be  so  much  increased  that  he  is  apt 
to  commit  murder  or  suicide. 

The  vegetative  processes  are  considerably  reduced. 
Sleep,  appetite,  digestion,  and  assimilation  of  food  are 
impaired.  The  blood  circulation  is  sluggish,  the  tem- 
perature of  the  body  is  somewhat  lowered.  The  strength 
of  tHe  patient  decreases.  Here  and  there  oedema  is  no- 
ticeable, especially  on  the  lower  extremities.  The  skin 
presents  a  cyanotic  appearance.  Graying  of  the  hair 
occurs  sometimes.  It  may  be  only  temporary,  the  hair 
assuming  its  previous  color  when  recovery  takes  place. 

Differential  Diagnosis.  Melancholia  may  be  con- 
founded with  primary  dementia.  Severe  acute  diseases 
sometimes  result  in  great  mental  exhaustion  representing 
a  complex  of  symptoms  which  is  very  similar  to  that  of 
melancholia  and  is  designated  as  primary  dementia  (p 
192).  This  psychosis  lacks  the  characteristic  depression 
of  melancholia,  the  patient  being  rather  in  an  indifferent 
than  in  a  sad  mood.  The  characteristic  delusions  of  self- 
depreciation  are  also  missing  in  primary  dementia. 
Finally,  the  immediately  preceding  exciting  cause,  which 
is  either  a  grave  infectious  disease  or  excessive  loss  of 
blood,  furnishes  a  differentiating  point  for  primary 
dementia. 

Melancholia  and  primary  insanity  or  paranoia  differ 
from  one  another  by  the  character  of  the  delusions.  In 
melancholia  ideas  of  self -depreciation,  the  consciousness 
of  guilt  and  sin,  oppress  the  patient;  in  paranoia  delu- 
sions of  grievance  prevail,  the  patient  believing  himself 


SPECIAL  PATHOLOGY  157 

to  be  wronged  without  deserving  it  in  the  least  (Ch.  28, 

PP-  57-58). 

Hallucinatory  insanity  resembles  melancholia  when 
the  contents  of  the  hallucinations  are  of  a  disagreeable, 
painful  nature  and,  therefore,  productive  of  a  sad  mood. 
But  in  hallucinatory  insanity  the  mood  changes  fre- 
quently, conforming  itself  to  the  hallucinations  present  at 
the  moment,  while  the  depression  of  melancholia  is  rather 
uniform  and  steady. 

Those  cases  of  delirium  which  resemble  melancholia 
differ  from  it  usually  by  the  presence  of  fever.  This  dif- 
ferentiating sign  is  the  more  reliable  as  a  melancholic 
patient  falling  ill  with  a  feverish  disease  becomes  free 
from  his  melancholia.  Besides,  the  usual  causative  factor 
of  delirium,  i.  e.,  intoxication,  is,  as  a  rule,  demonstrable. 

An  epileptic  patient  in  a  sad  mood  may  be  taken 
for  a  melancholic.  But  this  mistake  will  occur  only 
when  it  is  not  known  that  the  patient  is  epileptic.  The 
psychic  equivalents  (p.  243-244)  of  the  epileptic  attacks 
offer  many  differentiating  symptoms. 

Therapy.  The  treatment  of  melancholia  is  sympto- 
matic. Suicide  is  to  be  obviated  by  careful  watching 
which  is  especially  necessary  in  the  beginning  of  the  psy- 
chosis. Particular  precaution  is  required  during  the  emo- 
tional attacks  of  fear  because  the  energy  of  the  patient 
is  then  very  much  increased  and  he  displays  great  rage 
against  himself  and  others.  These  attacks  occur  chiefly 
in  patients  who  present  a  very  quiet  appearance,  and  at 
times  manifest  great  considerateness. 

Melancholies  often  refuse  food,  owing  to  their  delu- 
sions of  self -depreciation,  or  because  their  feelings  of 
anxiety  are  increased  when  their  stomach  is  filled.  In 
such  cases  the  patients  have  to  be  fed  artificially.      But 


158  PSYCHE 

even  when  the  patients  can  be  induced  to  take  much 
nourishment,  the  state  of  their  general  nutrition  remains 
poor  because  digestion  and  assimilation  are  impaired,  due 
to  certain  processes  obtaining  in  the  central  nervous  sys- 
tem. Tlie  patients  should,  therefore,  not  be  forced  to 
eat  more  than  is  just  necessary.  Through  certain  devices 
melancholies  refusing  food  may  be  influenced  to  take 
some  nourishment  (p.  144).  If  their  refusal  of  food  is 
founded  upon  delusions  of  self -depreciation,  upon  the 
idea  of  not  deserving  nourishment,  they  eat  something 
that  appears  discarded,  or  that  others  have  left  over. 

If  a  melancholic  patient  refusing  food  is  allowed  to 
hunger,  he  does  not  die  of  starvation,  but  he  may  be- 
come so  weak  that  a  slight  intercurrent  disease  may  prove 
fatal. 

It  is  entirely  useless  to  seek  to  disuade  a  melancholic 
patient  from  his  delusions.  His  condition  may  even  be 
made  worse  by  such  efforts  (pp.  32,  141). 

It  is  advisable  to  keep  melancholies  in  bed  for  some 
time  to  spare  their  strength  by  low^ering  the  expenditure 
of  bodily  heat.  But  this  rest  cure  must  not  be  exagger- 
ated, as  weakness  of  the  heart  is  apt  to  result  from  lack 
of  muscular  activity.  Oedema  occurring  in  melancholies 
is  to  be  treated  by  furthering  the  blood  circulation,  as  by 
warm  baths,  by  massage,  by  leading  the  patients  up  and 
down,  or  by  other  muscular  exercises. 

The  agitation  of  melancholic  patients  in  emotional 
attacks  of  anxiety  and  fear  may  be  somewhat  mitigated 
by  protracted  warm  baths  and  by  medicinal  sedatives. 
In  general,  however,  medicines  should  be  used  as  little 
as  possible.  For  the  prospect  of  recovery  is  so  much 
better,  and  convalescence  comes  so  much  sooner,  the 
less  the  brain  has  been  influenced  by  drugs  (p.  144). 


SPECIAL  PATHOLOGY  159 

Chapter  LXXIL 
STUPOR. 

Stupor  was  formerly  considered  as  a  form  of  melan- 
cholia. But  although  it  frequently  develops  from  melan- 
cholia, it  must  not  be  identified  with  it.  For  the  chief 
symptoms  of  melancholia  are  missing  in  stupor.  There 
is  neither  depression  of  mood  nor  excitative  anxiety  in 
stupor,  but  constant  indolence  without  any  emotional  agi- 
tation (Ch.  17,  pp.  36,  37).  At  times  stuporous  patients 
appear  to  be  excited,  a  certain  affective  state  prevailing  in 
which  they  create  the  impression  of  being  fascinated, 
spellbound.  They  fall  into  ecstasy  and  remain  in  this 
state  for  hours  and  days  without  the  slightest  fluctua- 
tion or  alteration  of  emotional  attitude,  the  mind  all  the 
while  being  absorbed  by  a  dominant  idea.  In  severe 
stupor  no  form  of  excitement  whatsoever  is  noticeable. 

The  ideational  process  is  at  a  standstill  or  a  single 
idea,  the  dominant  idea,  forms  the^  whole  contents  of  the 
consciousness.  Manifestations  of  the  will  are  entirely 
lacking.  The  patient  remains  motionless  for  hours  and 
days.  Even  the  reflex  movements  are  absent  or  dimin- 
ished. The  irritation  by  the  atmosphere,  ordinarily  caus- 
ing movements  of  the  eyelids,  has  no  effect  in  stupor. 
The  eyelids  hardly  respond  by  a  reflex  movement  to  an 
irritation  so  strong  as  to  produce  tears.  The  patient 
does  not  swallow  his  saliva  and  is  frequently  slavering. 
The  urine  is  not  evacuated  so  that  the  bladder  is  usually 
overfilled.  The  extremities  remain  in  one  and  the  same 
position  for  hours  and  days,  although  such  position  may 
be  very  uncomfortable  or  even  painful.  The  peculiar 
rigidity  of  the  muscles  in  such  conditions  has  been  desig- 


i6o  PSYCHE 

nated  as  flexibilitas  cerea.  The  vegetative  processes  are 
as  sluggish  as  the  voHtional  activity. 

Consciousness  and  orientation  are  considerably  im- 
paired in  stuporous  patients. 

The  condition  of  the  patient  sometimes  changes  un- 
expectedly: All  of  a  sudden  he  is  aroused  from  his 
lethargic  state  and  regains  consciousness  to  the  extent  of 
being  able  to  appreciate  his  circumstances.  The  lethargic 
condition  may  also  pass  suddenly  into  maniacal  excite- 
ment. These  attacks  are  not  of  long  duration  and  return 
to  the  former  lethargy. 

A  certain  stupor  occurs  which  does  not  correspond 
to  the  above  picture.  It  is  founded  on  a  terrifying  hallu- 
cination. The  patient  remains  rigid  in  the  posture  occu- 
pied at  the  moment  of  the  dreadful  hallucination,  and 
does  not  stir  for  fear  that  the  slightest  movement  may 
prove  disastrous. 

Differential  Diagnosis.  Stupor  resembles  primary 
curable  dementia  which  is  also  characterized  chiefly  by 
barrenness  of  the  ideational  and  affective  spheres  (Ch. 
1 7,  pp.  36,  2)7)'  But  in  stupor  the  poverty  of  ideas  is  often 
due  to  the  persistence  and  predominance  of  one  idea  pre- 
venting other  ideas  from  arising  in  the  field  of  conscious- 
ness. The  reflex  movements  are  not  impaired  in  primary 
dementia,  but  greatly  diminished  in  stupor.  Patients  suf- 
fering from  primary  dementia  never  show  the  peculiar 
rigidity  of  the  muscles — flexibilitas  cerea — which  is 
often  observed  in  stupor.  They  take  sufficient  nourish- 
ment and  have  no  disturbance  of  the  bladder.  Finally, 
in  primary  dementia  we  learn  through  the  anamnesis 
that  the  psychosis  has  been  preceded  by  excessive  loss  of 
blood  or  a  severe  infectious  disease. 

Secondary   dementia    (p.    189)    following  upon   an 


SPECIAL  PATHOLOGY  i6i 

acute  psychosis  may  sometimes  be  taken  for  stupor.  For 
the  ideational  sphere  may  have  been  greatly  devastated 
by  the  preceding  acute  mental  disorder.  But  although, 
in  some  instances,  secondarily  demented  patients  produce 
very  few  ideas,  their  mental  dullness  never  reaches  the 
extreme  degrees  met  with  in  stupor.  In  secondary  de- 
mentia the  reflexes  are  not  diminished,  sleep  and  appetite 
are  not  impaired,  and  rigidity  of  the  muscles  is  lacking. 
The  condition  of  the  patient  in  secondary  dementia  re- 
mains stationary  and  is  not  interrupted  by  sudden  tran- 
sitory changes  such  as. occur  in  stupor.  Finally,  in  sec- 
ondary dementia  the  anamnesis  shows  that  an  acute 
mental  disease  has  preceded. 

Therapy.  To  try  to  exert  a  psychical  influence  on 
a  stuporous  patient  is  a  useless  undertaking.  The  result 
obtained  by  mechanical  manipulations  is  very  slight  also. 
Special  attention  is  to  be  paid  to  the  nutrition  of  the 
patient.  The  attending  physician  must  know  what  and 
how  much  the  patient  eats.  If  the  patient  does  take  food 
handed  to  him,  the  nurses  may  be  permitted  to  feed  him. 
If  however  he  does  not  open  his  mouth  or  does  not 
swallow  the  food  forced  into  his  mouth,  artificial  feed- 
ing must  be  begun  early  and  carried  out  by  the  physician 
himself. 

Stuporous  patients  who  remain  sitting  on  one  spot, 
motionless  for  so  long  a  time  that  their  lower  extremities 
become  swollen,  should,  if  possible,  be  led  up  and  down 
the  room,  or  else  be  put  to  bed  and  massaged.  Bandag- 
ing the  legs  is  also  useful. 

The  attending  physician  should  not  rely  upon  the 
reports  of  the  attendants  regarding  the  functions  of  blad- 
der and  rectum,  but  should  examine  these  organs  from 
time  to  time  and  see  to  it  that  they  are  properly  evacu- 


i62  PSYCHE 

ated.  At  a  digital  examination  of  the  rectum,  he  will 
sometimes,  especially  in  female  patients,  find  it  filled 
with  an  enormous  quantity  of  faecal  masses  even  when 
the  patient  is  reported  to  have  diarrhoea. 

Stuporous  patients  are  very  liable  to  be  harmed  by 
fluctuations  of  the  atmospheric  temperature.  ■  In  cold 
weather  they  readily  acquire  chilblains,  and  exposed  to 
the  direct  sunrays  they  develop  symptoms  of  insolation. 
They  must,  therefore,  be  warmly  clad  in  winter  and  kept 
away  from  the  direct  sun  rays  in  hot  weather. 

Stuporous  patients  should  not  be  left  alone  with 
other  patients.  For  they  may  suddenly  be  seized  with 
an  attack  of  great  excitement  in  which  they  are  apt  to 
commit  dangerous  acts. 

Termination.  Stupor  may  end  in  recovery.  It  may 
also  pass  without  an  intermediary  stage  into  a  state  of 
maniacal  excitement,  the  clinical  picture  of  stupor  being 
henceforth  substituted  by  that  of  mania. 

It  is  remarkable  that  stupor  disappears  when  an 
acute  infectious  disease,  as  typhoid  fever,  intervenes.  The 
freedom  from  the  stupor,  however,  lasts  only  as  long  as 
the  infectious  disease  does;  when  the  latter  ceases,  the 
stupor  reappears. 


Chapter  LXXIII. 

MANIA. 

Remark.  The  clinical  picture  of  the  mental  disorder  called 
mania  consists  of  a  well  defined  complex  of  symptoms.  Morbid 
exaltation  of  the  mood  is  its  predominating  feature,  and  from  this 
all  other  symptoms  are  derived.  A  patient  presenting  this  clinical 
picture  is  called  a  maniac.  The  word  maniac  (manic,  maniacal),  in 
this  whole  treatise,  is  used  exclusively  in  this  sense,  but  not  in 
the   meaning   violently   insane,   which   it   usually  has   in   every-day 


SPECIAL  PATHOLOGY  163 

language.  Not  every  excited  insane  patient  is  a  maniac.  Melan- 
cholies and  patients  suffering  from  other  forms  of  insanity,  for 
instance,  hallucinatory  insanity,  may  be  as  restless,  agitated,  and 
violent  as  a  maniac.  The  term  manic-depressive  insanity  for  a 
certain  psychosis  (pp.  235-236)  is  not  very  appropriately  selected. 
For  the  two  component  parts  of  the  adjective  are  complete  opposites. 
And  yet  when  they  are  used  in  conjunction  to  characterize  a  patient, 
the  impression  is  created  that  he  is  suffering  at  the  very  same  time 
from  morbid  exaltation  and  morbid  depression.  In  a  strict  sense 
this  is  impossible,  nor  is  it  at  all  the  case  in  manic-depressive  in- 
sanity. For  setting  aside  the  so-called  mixed  states  (p.  237),  the 
theory  of  which  is  still  far  from  being  firmly  established  (p.  239), 
we  find  that  in  manic-depressive  insanity  the  patients  present  symp- 
toms of  exaltation  (manic)  at  some  periods  and  those  of  depression 
at  other  periods,  but  not  both  at  the  same  time.  This  psychosis 
has  been  called  periodic  (circular)  insanity — recurrent  insanity — 
which  term  is  certainly  less  misleading  than  the  designation  manic- 
depressive  insanity.  It  may  not  be  out  of  place  to  add  here  that 
some  psychiatrical  writings  are  greatly  lacking  in  clearness,  owing 
to  the  intermingling  of  the  popular  and  psychiatrical  significations 
of  the  word  maniac   (manic). 

Symptom-complex.  Morbid  exaltation  of  the 
mood  is  the  characteristic  symptom  of  mania.  Now 
and  then  the  patient  falls  into  an  angr}^  mood,  but  it  is 
merely  a  transitory  reaction  to  resistance  and  difficulties 
put  in  his  way  and  passes  away  quickly.  The  ideational 
process  is  accelerated,  the  memory  is  facilitated.  Hallu- 
cinations occur  in  one  or  in  several  senses.  Delusions  of 
grandeur  (Ch.  28,  p.  57)  are,  as  a  rule,  present.  The 
frequency  of  the  volitional  manifestations  is  increased 
(Ch.  37,  p.  77).  The  energy  is  augmented  with  regard 
to  the  application  of  great  muscular  power,  but  dimin- 
ished as  to  purposeful  and  persistent  action  (Ch.  41, 
p.  83).  The  vegetative  processes  are  enhanced,  due  to 
certain  causes  obtaining  in  the  central  nervous  system. 
Appetite  and  digestion  are  excellent  and  food  is  assimi- 
lated very  well.     Owing  to  his  great  exertions  the  patient 


1 64  PSYCHE 

loses  weight  and  strength,  but  much  less  than  would  nor- 
mally be  the  case  with  the  same  exertions.  Sleep  is 
reduced  a  good  deal. 

Clinical  Picture.  The  patient  is  constantly  in  a 
rosy  humor.  He  maintains  to  be  in  excellent  circum- 
stances and  to  enjoy  the  best  of  health.  On  his  coun- 
tenance rests  a  happy  expression,  his  eyes  are  glistening 
with  joy.  The  reasons  adduced  by  the  patient  to  explain 
his  great  cheerfulness  are  insufficient,  or  there  are  even 
causes  present  which  ought  to  produce  sadness.  The  ex- 
alted mood  is,  therefore,  of  morbid  nature  (Ch.  15,  p. 
34).  If  the  attempt  is  made  to  pull  the  patient  down 
from  his  heaven  of  bliss,  he  has  but  a  smile  of  pity  for 
the  bearer  of  the  ill  tidings,  or  gets  angry  at  him.  The 
cheerful  mood  lasts  exceedingly  long,  which  is  another 
criterion  for  its  being  morbid  (p.  35).  It  happens  that 
a  maniacal  patient  weeps.  But  this  is  already  a  sign  of 
approaching  convalescence,  indicating  that  the  patient 
now  and  then  is  in  a  normal  affective  state  and  recognizes 
his  misery  (pp.  128,  129).  Weeping  does,  therefore,  not 
exclude  mania,  but  is  an  indication  that  the  end  of  the 
mental  malady  is  not  far  off. 

The  acceleration  of  the  ideational  process  is  recog- 
nized chiefly  by  the  patient's  manner  of  talk.  He  is  very 
loquacious.  In  conversation  he  soon  gains  the  upper 
hand,  speaks  about  things  never  intended  to  be  drawn 
into  the  conversation,  and  wanders  quickly  from  one  sub- 
ject to  another.  It  appears  as  though  one  idea  would 
drive  the  other  away — flight  of  ideas — (pp.  36,  42). 
The  patient  shouts,  sings,  and  laughs,  thus  interrupting 
at  times  his  exuberant  talk.  In  aggravated  cases  the 
acceleration  of  the  ideational  process  may  be  so  great 
that  the  apparatus  of  speech  becomes  inadequate  to  fol- 


SPECIAL  PATHOLOGY  165 

low  and  express  the  ideas  rapidly  rushing  one  after  an- 
other. Only  fragments  of  sentences,  single  incoherent 
and  incomprehensible  words,  are  then  uttered.  The 
superabundance  of  ideas  is  manifested  also  by  the  pa- 
tient's ability  to  construct  rhymes. 

The  accelerated  course  of  ideas  brings  about  an  im- 
provement of  memory.  The  tension  in  the  nervous  ele- 
ments and  paths  is  raised  so  that  their  resistance  is  more 
easily  overcome  (Ch.  8,  p.  19).  The  reproduction  of 
memory  images  by  way  of  the  association  paths  is  thus 
facilitated.  The  patient  believes  to  be  clever  and  posr 
sesses  indeed  a  certain  wittiness.  When  the  maniacal 
excitement  is  slight,  a  layman,  easily  misled,  may  regard 
the  patient  merely  as  a  talkative,  merry  person. 

The  patient  is  laboring  under  delusions  of  grandeur. 
He  interprets  everything  to  his  favor,  overestimates  his 
powers,  and  underestimates  difficulties  and  obstacles.  He 
deals  with  persons  whom,  when  he  was  sane,  he  would 
accost  with  the  greatest  reverence,  in  the  most  familiar 
way  as  though  they  were  his  equals.  When  hallucina- 
tions supervene  or  when  the  maniacal  excitement  is  great, 
the  delusions  are  more  pronounced.  The  patient  then 
believes  to  be  possessed  of  great  wealth,  to  be  an  emi- 
nent personage  who,  by  his  own  unlimited  power,  will 
bring  order  and  rule  into  this  wicked  world.  The  delu- 
sions either  bear  the  mark  of  the  irrational  and  ridiculous, 
thus  being  absurd  delusions  of  grandeur  (pp.  55,  56)  ;  or 
else  they  are  explained  by  the  patient  in  a  fairly  plausible 
way.  Whether  one  or  the  other  is  the  case  depends  upon 
the  basis  of  the  psychosis.  In  mania  of  general  paresis 
the  delusions  are  almost  always  characterized  by  absur- 
dity. The  patient  asserts  he  possesses  billions,  is  the 
emperor  of  China  or  some  divinity.     He  often  contra- 


1 66  PSYCHE 

diets  himself  without  being  sensible  to  the  contradiction. 
In  mania  of  periodic  insanity,  hereditary  insanity,  senile 
insanity,  however,  fairly  good  reasons  are  adduced  by 
the  patient  for  his  delusions  of  grandeur  (pp.  55,  56). 

Hallucinations  are  rarely  wanting  in  mania.  They 
are  interpreted  by  the  patient  to  his  advantage.  They 
confirm  what  he  believes  and  wishes.  If  they  do  not, 
he  reacts  towards  them  with  outbursts  of  anger. 

The  increased  frequency  of  volitional  manifestations 
is  expressed  by  a  constant  impulse  for  movement.  The 
movements  are  carried  out  for  their  own  sake  and  have 
no  special  aim.  In  the  open  air  the  patient  rambles  about, 
runs,  jumps.  When  he  is  isolated,  he  tugs  at  his  clothes, 
tears  them,  handles  his  excretions,  smearing  the  walls 
and  other  objects  with  them.  Especially  female  patients 
wallow  on  the  floor,  pluck  at  their  hair  and  dirty  it  with 
their  excrements.  These  manipulations  have  been  called 
symptoms  of  isolation.  As  a  rule,  the  maniacs  are  hoarse 
after  their  excitement  has  lasted  a  few  days,  owing  to 
the  constant  talking,  singing,  shouting. 

The  augmentation  of  the  energy  of  force  (p.  83) 
is  exhibited  by  an  excess  of  power  in  all  actions.  The 
movements  of  the  patient  are  forceful,  extravagant  in 
strength.  In  conversation  he  shouts.  Requested  not  to 
speak  so  loudly,  he  lowers  his  voice  for  a  moment  to 
resume  the  former  loud  tone  after  a  while.  In  writing 
he  makes  powerful  long  strokes.  It  is  interesting  to 
observe  the  handwritings  of  a  paretic  patient  in  the  ma- 
niacal and  melancholic  stages.  They  can  be  clearly  dis- 
tinguished, and  thus  the  stage  of  the  psychosis  to  which 
each  handwriting  belongs  can  be  established.  It  has  been 
maintained  that  patients  in  maniacal  excitement  are  pos- 
sessed of  greater  strength  than  they  normally  have,  per- 


SPECIAL  PATHOLOGY  167 

haps  due  to  certain  processes  obtaining  in  the  central  nerv- 
ous system.  But  it  is  possible  that  the  movements  of 
maniacs  bear  an  excess  of  power  because  the  considera- 
tion does  not  enter  their  mind  that  they  are  liable  to 
derive  harm  from  waste  of  strength  (pp.  83-84). 

With  regard  to  persistent  action,  however,  the 
energy  of  the  maniac  is  lessened.  He  is  unable  to  con- 
centrate his  attention  upon  a  subject  and  readily  yields 
to  incidental  impulses.  Any  intervening  perception  is 
sufficient  to  divert  him  from  what  he  had  just  intended 
to  do.  By  directing  his  attention  to  another  object  he 
may  be  made  to  give  up  a  design  which  he  seemed  to  be 
intent  upon  carrying  out.  This  peculiarity  of  the  maniac 
brings  about  his  '' tractahility"  which  is  of  great  impor- 
tance in  the  treatment  (p.  86).  In  an  outburst  of  vio- 
lence necessitating  great  force  to  subdue  the  patient,  one 
can  manage  him  without  much  difficulty  by  resorting  to 
the  maniacal  tractability. 

As  to  the  vegetative  processes,  sleep  is  reduced. 
Nevertheless  the  strength  of  the  patient  remains  fairly 
well  preserved.  He  does  not  look  exhausted,  although 
he  loses  a  little  weight.  The  face  appears  ruddy,  the 
eyes  glisten.  This  preservation  of  the  patient's  strength 
notwithstanding  excessive  physical  and  mental  exertion 
is  founded  on  certain  causes  which  prevail  in  the  central 
nervous  system.  The  patient  eats  much,  digests  and  as- 
similates the  food  very  well.  The  fact  that  maniacs  do 
not  become  exhausted  with  all  their  great  exertions  is 
very  important  for  the  distinction  of  malingerers  from 
patients. 

Differential   Diagnosis.     The    monomanias 


i68  PSYCHE 

(pp.  88,  89),  such  as  kleptomania,  pyromania,  phono- 
mania*,  etc.,  do  not  belong  to  mania  proper  at  all.  The 
pyromaniacs  are  usually  idiots  (p.  199),  the  kleptomaniacs 
are  paretics,  the  phonomaniacs*  are  paranoiacs  laboring 
under  certain  delusions.  At  best  nymphomania  may  be 
brought  into  relation  to  maniacal  excitement.  Especially 
female  maniacs  exhibit  great  sexual  excitement,  uttering 
the  most  obscene  exclamations  relating  to  the  sexual 
activity. 

Not  every  restless,  boisterious  patient  is  a  maniac. 
Melancholies  in  an  emotional  attack  (p.  154)  are  also 
restless  and  violent,  but  fear  is  the  foundation  of  their 
agitation,  which  excludes  mania. 

Course  and  Prognosis.  Maniacs  may  be  com- 
pletely restored  unless  the  basis  of  their  mental  disease  is 
unfavorable  as  is  the  case,  for  instance,  in  general  par- 
esis. The  extent  of  the  patient's  agitation  is  irrelevant 
as  regards  his  recovery. 

The  maniacal  excitement  may  pass  into  melancholia 
as  in  hereditary  insanity  or  periodic  insanity.  The  change 
occurs  sometimes  quite  suddenly;  in  the  course  of  one 
night  the  clinical  picture  assumes  an  entirely  different 
aspect,  so  that  the  patient  can  hardly  be  recognized  on 
the  following  day. 

During  convalescence  maniacal  patients  frequently 
show  a  considerable  abatement  of  strength.  When  the 
causes  prevailing  in  the  central  nervous  system  for  the 
enhancement  of  the  vegetative  processes  have  ceased 
with  the  discontinuance  of  the  psychopathological  process, 
the  patients  may  pass  into  a  state  of  great  physical  and 
mental  exhaustion  as  a  result  of  the  preceding  exertions. 


*  The  derivation  of  phonomania,  phonomaniac,  is  explained  in 
the  foot-note  on  p.  88. 


SPECIAL  PATHOLOGY  169 

The  further  prognosis  is  to  be  given  with  great  caution. 
The  assumption  must  not  be  made  forthwith  that  the 
acute  mental  disorder  has  ended  in  permanent  feeble- 
mindedness. For  a  long  time  is  necessary  for  some  pa- 
tients to  recover  from  the  enormous  exertions  they  have 
gone  through  during  the  maniacal  excitement.  It  is, 
however,  possible  that  the  mental  weakness,  noticeable 
when  the  acute  pathological  process  has  ceased,  remains 
permanent,  i.  e.,  that  the  mania  has  terminated  in  sec- 
ondary dementia,  secondary  feeble-mindedness. 

Therapy.  In  the  management  of  maniacal  patients 
their  "tractability"  (p.  167)  affords  valuable  aid  when 
employed  judiciously.  No  direct  resistance  must  be 
offered  them,  nor  their  desires  flatly  refused.  By  direct- 
ing their  attention  to  some  other  object  they  can  be  in- 
duced to  abandon  their  intentions.  Care  must  be  taken 
that  certain  desires  are  not  awakened  in  them.  Danger- 
ous instruments,  objects  of  value,  etc.,  must  be  kept  out 
of  their  sight. 

It  is  necessary  to  see  to  it  that  the  patients  do  not 
become  exhausted  through  overexertion.  Exhaustion  is 
likely  to  occur  especially  in  mania  of  senile  insanity. 
Sometimes  artificial  appeasement  through  hypnotics  is 
indicated  to  prevent  exhaustion.  In  juvenile  patients 
exhaustion  is  not  to  be  feared  much,  yet  caution  is  re- 
quired. For  the  patients  are  readily  liable  to  contract 
injuries  through  their  agitated  conduct,  and  injuries  in 
maniacs  are  very  dif^cult  to  treat.  For  the  same  reason, 
care  must  be  taken  that  the  patients  do  not  swallow  food 
of  extreme  temperature  or  otherwise  dangerous.  They 
must  not  be  allowed  to  smoke,  to  drink  in  excess,  etc. 


I/O  PSYCHE 


Chapter  LXXIV. 
HALLUCINATORY    INSANITY. 

The  occurrence  of  a  psychosis  characterized  1)y 
hallucinations  as  the  chief  feature  has  been  called  in  ques- 
tion. But  there  is  a  clinical  entity  of  insanity  in  which 
hallucinations  form  the  primary  and  dominant  symptom 
giving  rise  to  all  the  other  psychopathic  manifestations. 
This  mental  disease  may,  therefore,  be  appropriately 
designated  as  hallucinatory  insanity. 

Symptom-complex.  The  principal  symptom  of  the 
psychosis  are  hallucinations.  They  occur  in  one  or  in 
several  senses  and  determine  the  affective  state  (p.  14). 
The  latter  show^s  no  primary  disturbance,  but  is  only  sec- 
ondarily changed ;  exaltation,  depression,  or  angry  mood, 
etc.,  prevails  according  to  the  character  of  the  hallucina- 
tions. The  affective  state,  in  turn,  influences  the  course 
of  ideas  accelerating  or  retarding  it  (Ch.  7,  p.  18).  The 
memory  is  facilitated  when  the  affective  state  is  exalted, 
and  impeded  w^hen  it  is  depressed.  The  frequency  of  the 
volitional  manifestations  is  increased  or  diminished,  de- 
pending upon  the  affective  state.  The  vegetative  proc- 
esses, too,  are  affected  only  secondarily.  Appetite,  diges- 
tion, and  assimilation  may  be  disturbed  or  normal.  Some 
patients  reject  food  and  decline  in  strength,  but  to  no 
greater  extent  than  a  normal  individual  taking  no  nour- 
ishment. When  appetite  and  sleep  are  not  disturbed, 
the  state  of  the  general  nutrition  remains  satisfactory. 

Clinical  Picture.  The  clinical  picture  of  hallu- 
cinatory insanity  is  very  manifold.  For  it  varies  accord- 
ing to  whether  the  hallucinations  take  place  frequently  or 
rarely,    whether   they   are   of   agreeable   or   disagreeable 


SPECIAL  PATHOLOGY  171 

nature,  and  whether  one  or  several  senses  are  involved  in 
the  hallucinations. 

Some  patients  hallucinate  very  rarely.  Thus  in  tak- 
ing the  anamnesis  in  a  case  of  hallucinatory  insanity  we 
may  learn  that  some  ten  years  ago  the  patient  had  "heard 
a  voice"  and  had  not  known  what  to  make  of  this.  Such 
a  patient  is  greatly  perplexed  by  his  hallucination,  unable 
to  explain  to  himself  the  strange  phenomenon,  and  is 
afraid  or  ashamed  to  confide  his  experience  to  any  one. 
Such  cases  of  hallucinatory  insanity  will  remain  doubt- 
ful, for  a  long  time  at  least,  because  the  patients  conceal 
their  hallucinations  which  worry  them  only  once  in  a 
great  while. 

It  occurs  that  a  person  all  of  a  suddent  becomes 
greatly  agitated,  frantic,  and  performs  violent  acts 
which  cause  his  commitment  to  an  insane  asylum. 
Here  he  is  perfectly  quiet  and  composed  and  it  is 
impossible  to  notice  anything  abnormal  in  him.  The 
diagnosis  transitory  insanity  should  not  be  advanced 
forthwith  in  such  a  case,  for  it  does  not  explain 
the  case.  But  we  should  rather  bear  in  mind  that 
the  patient's  strange  behavior  may  have  been  due  to 
hallucinations  which  he  is  now  unwilling  to  reveal. 
Change  of  locality  is  also  to  be  taken  into  consideration. 
For  hallucinating  patients  become  free  from  their  hallu- 
cinations, for  some  time  at  least,  when  they  are  removed 
from  their  accustomed  surroundings.  A  prisoner,  for 
instance,  is  seized  with  hallucinatory  insanity  and  com- 
mits strange  acts.  Brought  thereupon  into  the  insane 
asylum  for  observation,  he  shows  a  normal  behavior. 
Only  after  a  long  interval  a  change  may  again  take  place 
in  the  conduct  and  character  of  the  patient,  proving  him 
to  be  insane  and  revealing  the  nature  of  the  psychosis. 


172  PSYCHE 

Hallucinatory  insanity  of  this  form  is  very  commonly 
designated  as  transitory  insanity. 

In  another  instance  a  patient  is  brought  into  the 
asylum  in  a  state  of  great  confusion.  He  is  very  rest- 
less, excited,  violent,  and  covers  his  face  and  ears  as 
though  to  avoid  seeing  and  hearing.  He  creates  the  im- 
pression of  being  in  delirium.  In  such  cases  it  is  also  at 
first  impossible  to  obtain  from  the  patients  a  proper  ac- 
count about  their  mental  attitude,  and  hallucinatory  in- 
sanity can  only  be  surmised.  When  the  patients  become 
free  from  their  hallucinations,  their  confusion  and  agi- 
tation cease,  and  then  it  may  be  possible  to  establish  that 
they  had  been  under  the  influence  of  hallucinations. 

A  third  clinical  picture  of  hallucinatory  insanity  is 
manifested  in  the  following  way.  The  patient  is  con- 
siderably excited  once  in  a  while,  changes  his  domicile 
several  times  without  adequate  reasons,  and  suddenly 
performs  a  violent  act  which  causes  his  commitment  to 
the  insane  asylum.  Here  he  relates  he  has  repeatedly 
"heard"  or  ''seen"  this  and  that  and  has  been  unable  to 
interpret  his  experiences,  but  now  he  understands  every- 
thing after  the  physician  has  explained  to  him  that 
all  his  troubles  have  been  brought  about  by  sense  decep- 
tions. 

Again  in  another  instance  the  patient  makes  re- 
peated attempts  at  suicide,  is  depressed  or  agitated,  tears 
his  clothes,  refuses  food,  laments  loudly  that  he  will 
soon  be  thrown  into  prison,  executed,  etc.  His  condition 
would  suggest  the  diagnosis  melancholia  (melancholia 
agitata).  Questioned  on  what  he  bases  his  fear  of  being 
arrested,  beheaded,  he  replies  he  has  ''heard  people  say" 
that  he  has  committed  a  crime ;  but  these  imputations  do 
not  contain  a  particle  of  truth.     Such  an  answer  shows 


SPECIAL  PATHOLOGY  173 

that  the  patient  is  hallucinating,  for  it  represents  the 
characteristic  contents  of  a  hallucination. 

Other  patients  complain  that  they  are  continually 
vexed  by  strange  perceptions  of  hearing  and  sight.  They 
implore  their  friends  and  their  physician  to  relieve  them 
from  these  intolerable  sufferings.  Suddenly  their  con- 
dition is  changed  and  they  are  entirely  composed;  they 
are  rid  of  their  tormenting  hallucinations  for  a  day  or 
two.    Then  the  same  play  is  repeated. 

Thus  hallucinatory  insanity  presents  widely  differing 
clinical  pictures.  The  patients  may  be  quiet,  agitated, 
violent,  confused,  desperate,  intent  upon  suicide,  waver- 
ing, etc. 

Differential  Diagnosis.  A  hallucinating  patient 
may  be  taken  for  a  maniac.  But  after  a  few  days'  ob- 
servation it  happens  that  the  patient  refuses  food.  The 
diagnosis  mania  is  then  to  be  provided  with  a  question 
mark.  It  may,  indeed,  be  the  case  that  a  maniac  does  not 
take  nourishment,  because  he  does  not  find  time  to  eat,  as 
it  were,  or  because  he  is  unable  to  carry  out  the  movements 
necessary  for  eating,  due  to  flight  of  ideas.  But  if  an 
attendant  helps  him,  steadying  his  hands  and  arms  or 
handing  him  the  food,  he  takes  it  even  with  eagerness. 
A  hallucinating  patient,  however,  will  persist  to  refuse 
food  in  spite  of  such  help. 

Paranoia  is  to  be  taken  into  consideration.  If  the 
patient  is  excited,  believing  to  be  unjustly  persecuted, 
this  delusion  of  grievance  (Ch.  28,  p.  57)  may  intimate 
paranoia.  But  the  hallucinating  patient  never  exhibits 
the  peculiar  tendency  of  drawing  conclusions  from  his 
perceptions  as  does  the  paranoiac;  he  would  not  see  in 
insignificant  incidents  proofs  for  his  delusions,  as  would 
the  paranoiac.     His  judgment  is  still  sound  in  this  re- 


174  PSYCHE 

spect.  Besides,  the  paranoiac  usually  harbors  at  the 
same  time  delusions  of  being  furthered  (Ch.  29,  p.  58) 
and  tries  to  bring  them  in  accord  with  his  delusions  of 
being  wronged,  explaining  the  contradiction  between 
both  and  combining  them  into  one  system  (systematized 
delusions).  The  hallucinating  patient  does  not  think  so 
systematically  with  regard  to  his  delusions.  Moreover, 
since  hallucinations  are  caused  by  certain  irritative  states 
of  the  brain  cortex,  their  contents  will  not  be  stable, 
but  subject  to  frequent  changes.  While  the  paranoiac 
is  controlled  by  definite  and  comparatively  lasting  ideas, 
the  hallucinating  patient's  mental  attitude  is  dependent 
upon  what  he  just  happens  to  "hear"  or  "see."  To-day 
he  may  be  in  one  frame  of  mind,  to-morrow  in  another 
one. 

Hallucinatory  insanity  resembles  melancholia  when 
the  patient  is  in  despair  or  excitative  fear.  But  this  sec- 
ondary apprehensive  anxiety  of  the  hallucinating  patient 
is  distinguished  from  the  primary  one  of  the  melancholic 
by  the  delusions  present.  In  melancholia  delusions  of 
self -depreciation  are  usually  demonstrable.  The  patient 
believes  to  deserve  the  persecutions  he  complains  about. 
This  suppression  of  self-esteem  is  absent  in  the  hallucin- 
ating patient.     He  considers  himself  innocent. 

Prognosis  and  Etiology.  Hallucinatory  insanity 
may  be  followed  by  restitutio  ad  integrum,  and  this  some- 
times quite  suddenly  with  the  cessation  of  the  hallucina- 
tions. The  mental  disturbance  lasts  in  some  cases  only  a 
few  weeks.  In  other  instances  the  hallucinations  com- 
mence slowly  and  persist  for  years.  Some  patients  re- 
main the  prey  of  their  hallucinations  for  ten  years  and 
longer.  But  even  after  many  years'  duration  complete 
recovery  may  ensue. 


SPECIAL  PATHOLOGY  175 

Intoxication  is  frequently  at  the  basis  of  hallucin- 
atory insanity  (morphine,  cocaine).  Sometimes  sud- 
den withdrawal  of  an  accustomed  stimulant  furnishes 
the  etiological  factor  of  the  psychosis.  The  removal  of 
the  intoxicating  agent  or  careful  administration  of  the 
habitual  excitant  may  restore  the  patient's  health.  Very 
often  trauma  is  the  cause  of  hallucinatory  insanity.  In 
such  cases  the  hallucinations  may  disappear  and  the  pa- 
tient recover  when  the  consequences  of  the  concussion  of 
the  brain  have  ceased.  The  prognosis  of  traumatic 
hallucinatory  insanity  is,  therefore,  not  unfavorable.  Yet 
it  is  to  be  given  with  caution  since  the  hallucinations 
may  in  any  case  persist  for  years.  It  also  occurs  in 
traumatic  hallucinatory  insanity  that  after  some  time  the 
patient  becomes  free  from  his  hallucinations  and  is  en- 
tirely normal  for  a  long  time,  and  then  the  mental  dis- 
order sets  in  again  in  its  former  intensity. 

Therapy.  In  the  treatment  of  hallucinatory  in- 
sanity it  is  necessary  to  bear  in  mind  that  a  hallucinating 
patient  is  entirely  unreliable.  He  may  be  cheerful,  quiet, 
harmless  to-day,  despondent,  violent,  dangerous  the  next 
day.  The  compelling  force  of  the  hallucinations  is  apt 
to  drive  the  patient  into  committing  atrocious  misdeeds. 
Intelligent  patients  report  that  the  hallucinations  are 
sometimes  followed  by  irresistible  impulses  for  certain 
acts  (Ch.  25,  p.  52).  The  momentary  suggestion  of  a 
hallucination  may  thus  instigate  a  crime.  Hallucinating 
patients,  therefore,  require  careful  watching. 

When  the  cause  of  hallucinatory  insanity,  e.  g.,  in- 
toxication, abstinence,  or  trauma,  has  been  established,  the 
attempt  is  to  be  made  to  remove  the  harmful  conse- 
quences of  these  etiological  factors. 


176  PSYCHE 

Chapter  LXXV. 
PRIMARY    INSANITY,    PARANOIA. 

Symptom-complex.  Primary  insanity  or  paranoia, 
unlike  secondary  insanity  (p.  i8i),  develops  during  a 
state  of  normal  health.  The  mental  disorder  starts  with 
a  peculiar  affective  state.  The  patient  commences  to  be 
constantly  harrassed  by  an  indefinable  feeling  of  being 
observed,  of  being  the  object  of  everybody's  attention, 
partly  in  a  benevolent,  partly  in  a  malicious  sense.  He 
feels  ill  at  ease,  his  mental  tranquillity  is  disturbed,  be- 
cause he  imagines  that  all  the  people  around  him  are 
concerned  about  him.  The  ideational  sphere  shows  noth- 
ing remarkable  as  to  the  frequency  of  ideas  arising  in 
consciousness,  but  is  characterized  by  definite  delusions, 
by  ideas  of  being  furthered  and  wronged  (pp.  55-59), 
by  ideas  of  furtherance  and  grievance.  These  two  forms 
of  delusions  are  brought  in  accordance  with  each  other, 
and  contradictions  between  them  are  explained  with 
some  measure  of  plausibility  (Ch.  29,  p.  58).  The  delu- 
sions are  corroborated  by  hallucinations.  The  frequenc}- 
of  the  volitional  manifestations  is  not  changed,  or  not 
unusual.  The  energy  dependent  upon  tlte  delusions  is 
sometimes  considerably  increased  (p.  85).  In  the  vege- 
tative sphere  there  is  impairment  of  sleep,  owing  to  great 
excitability.  The  willingness  to  take  nourishment  is  in- 
fluenced by  the  delusions.  Some  patients  eat  normally, 
others  abstain  from  food.  Within  this  complex  of  symp- 
toms there  are  many  forms  of  primary  insanity. 

Clinical  Picture.  In  a  state  of  fairly  good  health 
the  patient  commences  to  feel  uneasy.  Everything  around 
him  gives  him  the  impression  as  though  "something  was 
the  matter."     He  is  constantly  annoyed  by  the  thought 


SPECIAL  PATHOLOGY  177 

that  he  has  mistaken  his  vocation,  that  he  had  been 
destined  to  occupy  a  more  important  position  in  Hfe  than 
he  does.  This  mood  often  arises  quite  suddenly.  Many 
a  patient  reports  he  had  changed  his  domicile  to  avoid 
certain  annoyances.  In  the  new  place  he  had  lived  with 
a  tranquil  mind  for  a  long  time.  Incidentally  somebody 
looked  at  him  in  a  strange  manner,  and  from  this  mo- 
ment his  mental  tranquillity  was  gone.  After  another 
change  of  residence  he  had  made  a  similar  experience. 

In  the  mood  just  outlined  the  patient  is  unable  to 
perceive  things  correctly  and  misinterprets  circumstances 
and  occurrences.  He  attributes  significance  to  everything 
he  sees  and  hears,  although  in  reality  it  is  of  no  impor- 
tance and  has  no  relation  whatsoever  to  his  person  (pp. 
74-75).  In  any  newspaper  article  he  reads  reports  that 
concern  him.  The  feeling  of  being  a  person  about  whom 
people  busy  themselves  a  good  deal,  leads  him  to  the  belief 
that  he  is  a  man  of  great  importance.  He  argues  after 
this  manner :  'T  am  a  plain  person,  have  never  attempted 
to  force  myself  to  the  front:  why  do  the  people  con- 
stantly direct  their  attention  toward  me?  There  must 
be  something  to  it."  In  this  way  he  arrives  at  certain 
wrong  notions,  i.  e.,  at  delusions,  even  without  the  inter- 
vention of  hallucinations.  The  delusions  become  more 
definite  and  pronounced  when,  after  some  time,  hallu- 
cinations supervene.  The  auditory  hallucinations  are 
usually  short,  restricted  to  a  few  words,  infinitives  or 
imperatives,  as  ''there  he  comes  \"  ''looks  like  the  prince," 
"favorite  of  the  king,"  "to  arrest,"  "run!"  "shoot!" 
"catch!"  etc. 

The  hallucinations  impart  exactness  to  the  patient's 
delusions.  From  a  certain  exclamation  he  derives  the 
conviction  that  he  is  not  descended  from  the  man  who 


178  PSYCHE 

has  passed  for  his  father  until  now,  but  from  a  prince. 
He  beHeves  to  have  a  claim  to  the  throne.  Now  he  is 
able  to  explain  to  himself  why  some  time  ago  somebody 
had  gazed  at  him  with  a  look  portenting  evil.  This  per- 
son was  a  rival  of  his  who  had  the  intention  to  do  away 
with  him  by  foul  means  in  order  to  acquire  the  throne. 
The  patient  tries  to  bring  the  events  of  his  former  life 
into  relation  to  his  present  ideas,  to  recall  from  his  early 
youth  occurrences  which,  already  at  that  time,  pointed 
to  his  future  greatness,  to  his  being  descended  from  a 
king,  etc. — systematized  delusions.  It  occurs  to  him  that 
his  teacher  had  given  him  a  picture  with  a  crown  on  it, 
that  his  mother  had  told  him  a  story  of  a  prince,  that  a 
high  personage  had  shaken  hands  with  him  and  had 
treated  him  very  graciously,  etc.  All  this  intimated  that 
he  was  entitled  to  the  throne.  Now  he  wants  to  take  a 
decisive  step  toward  the  acquisition  of  the  crown.  He 
changes  his  domicile  and  undertakes  long  journeys  to 
get  out  of  the  way  of  his  adversaries  and  to  be  undis- 
turbed in  the  pursuit  of  his  aim.  He  even  abandons  his 
vocation.  Relatives  and  neighbors  soon  notice  that  he 
has  become  irrational  and  irresponsible.  Now  and  then 
he  makes  threatening  remarks  against  people  whom  he 
imagines  to  be  his  enemies.  In  this  stage  the  patient  has 
become  a  public  danger,  and  his  commitment  to  the  in- 
sane asylum  takes  place.  Here  he  assures  the  physician 
everything  he  has  told  him  is  absolutely  true,  although  it 
may  sound  rather  incredible. 

In  some  instances  the  delusions  and  through  these 
the  whole  clinical  picture  bear  a  religious  character.  The 
patients  imagine  to  have  been  selected  by  God  to  redeem 
the  wicked  world  and  to  be  persecuted,  therefore,  by  the 
Evil  One.     Most  forms  of  religious  insanity  belong  to 


SPECIAL  PATHOLOGY  179 

paranoia.  Formerly  religious  paranoia,  in  which  divine 
suggestions,  demoniacal  possession,  belief  in  devilry,  etc., 
played  a  prominent  part,  was  quite  frequent.  Nowadays 
more  modern  delusions  figure  frequently  in  paranoia. 
The  patients  believe  to  be  chloroformed,  electrized,  hyp- 
notized, to  hear  telephonicall}^  to  receive  messages  by 
wireless  telegraphy,  to  see  by  means  of  X-rays,  to  soar 
high  above  the  clouds  in  a  dirigible  air-craft,  etc.  The 
hallucinations  and  delusions  in  paranoia,  the  same  as  in 
other  psychoses,  are  modernized,  as  it  were,  the  latest 
invention  being  brought  into  play  in  their  formation. 

The  delusions  play  the  principal  part  in  the  clinical 
picture  of  paranoia.  They  are  well  distinguished  from 
similar  delusions  of  other  psychoses.  The  paranoiacs 
are  not  possessed  by  the  consciousness  of  guilt  and  sin, 
but  believe  to  be  innocent  and  regard  their  persecutors 
as  malicious  persons  who  try  to  harm  them  for  no  just 
cause.  Their  persecutory  ideas  are,  therefore,  delusions 
of  grievance.  These  often  resemble  the  melancholic  de- 
lusions of  self -depreciation.  But  there  is  a  marked  dif- 
ference between  both.  In  paranoia  the  patient's  self- 
esteem  is  not  diminished  in  the  least,  but  in  melancholia 
it  is  greatly  lowered  (Ch.  28,  p.  57). 

The  paranoiic  delusions  of  furtherance  are  similar 
to  delusions  of  grandeur.  But  the  primarily  insane  pa- 
tient does  not  have  the  feeling  of  being  able  to  attain  to 
greatness  through  his  own  unlimited  powers.  He  owes 
all  his  present  and  prospective  successes  to  his  descent, 
to  the  benevolence  of  His  Majesty,  of  the  Holy  See,  of 
God,  etc.  He  is  therefore  controlled  by  ideas  of  being 
the  object  of  favor  and  bounty.  He  cannot  help  being 
destined  for  an  excellent  future. 

Paranoiacs  are  often  quick  at  repartee  in  solving 


i8o  PSYCHE 

contradictions  prevailing  between  their  delusions  of  fur- 
therance and  those  of  grievance. 

Forensic  Consideration.  The  delusions  may  in- 
duce the  paranoiacs  to  perform  all  kinds  of  offensive  acts. 
Some  patients  inflict  injuries  on  themselves.  Self -mutila- 
tion of  the  genital  organs,  for  instance,  occurs  in  religious 
paranoia.  Other  patients  imagine  that  their  strength  is 
being  diverted  from  them,  that  life-blood  and  other  vital 
juices  are  withdrawn  from  their  body.  They  drink, 
therefore,  their  own  urine,  hoping  to  regain  their  vigor 
through  it.  Another  paranoiac  conceives  the  notion  that 
the  blood  of  a  child  or  the  testicles  of  a  young  boy  will 
render  him  invincible  and  invulnerable.  This  notion  may 
lead  him  to  commit  atrocities  or  murder.  Driven  by 
delusions  the  paranoiacs  make  murderous  attacks  upon 
people  coming  in  their  way.  60  to  70%  of  the  assaults 
upon  kings,  princes,  and  high  dignitaries  are  due  to  prim- 
ary insanity.  The  paranoiacs,  therefore,  come  often  into 
conflict  with  the  Penal  Code.  They  frequently  know 
very  well  that  their  acts  are  criminal.  They  admit  that 
they  had  known  it,  and  their  sole  defense  is  that  they 
had  committed  the  crime  in  order  that  their  cause  might 
become  known  to  the  public,  and  their  adversaries  be 
severely  punished. 

Differential  Diagnosis.  In  cases  where  primary 
insanity  resembles  melancholia  or  mania  an  exact  ana- 
lysis of  the  delusions  will  exclude  these  psychoses.  In 
hallucinatory  insanity  the  mood  of  the  patient  changes 
very  often,  while  in  paranoia  the  patient's  emotional  at- 
titude is  comparatively  lasting.  Besides,  the  hallucinat- 
ing patient  is  not  possessed  of  well-defined  ideas  of  fur- 
therance and  grievance.  The  differentiation  from  sec- 
ondary insanity  will  be  pointed  out  later. 


SPECIAL  PATHOLOGY  i8i 

Course.  Primary  insanity  is  sometimes  interrupted 
by  a  transitory  standstill  during  which  the  patient  appears 
entirely  normal.  After  a  lapse  of  some  time  the  mental 
disease  sets  in  again.  Caution  is,  therefore,  required  in 
giving  the  prognosis  after  all  morbid  symptoms  of  para- 
noia have  disappeared.  Complete  recovery  must  not  be 
assumed  before  a  sufficient  time  has  passed  without  signs 
of  mental  disorder.  Paranoia  as  such  never  leads  to 
death.  The  mental  disease  may  last  10-20  years,  and  yet 
the  patient  may  remain  in  a  fairly  good  physical  con- 
dition. 

Therapy.  The  treatment  of  paranoia  is  purely 
symptomatic.  Artificial  feeding  becomes  necessary  in 
some  cases  (p.  143).  The  primarily  insane  patients  are 
dangerous  to  themselves  and  to  others  and  must,  there- 
fore, be  carefully  watched,  especially  in  view  of  the  fact 
that  they  are  often  very  circumspect.  They  are  capable 
of  simulating  recovery  before  their  physician  and  their 
relatives  to  gain  a  free  hand  for  the  execution  of  their 
pernicious  plans. 

Chapter  LXXVI. 
SECONDARY    INSANITY. 

Secondary  insanity  develops  from  primary  insanity 
or  forms  its  continuation.  It  is,  therefore,  important  to 
draw  the  dividing  line  between  the  two,  to  determine 
when  a  paranoiac  is  to  be  considered  as  secondarily 
insane. 

Symptom-complex.  The  affective  sphere  shows  no 
disturbance.  The  patient's  mood  is  normal  and  tranquil 
as  long  as  his  fixed  ideas  are  not  evoked.  The  ideational 
sphere  is  characterized  by  fixed  delusions  (Ch.  30,  p.  59) 


i82  PSYCHE 

which  constitute  the  pathognomonic  symptom  of  the 
mental  disease.  The  voHtional  activity  is  not  disturbed, 
but  the  fixed  delusions  sometimes  cause  an  increase  of 
energy  (p.  85).  In  the  vegetative  sphere  there  is  noth- 
ing abnormal.  Sleep  is  not  impaired.  Appetite,  diges- 
tion, and  assimilation  are  good. 

Clinical  Picture.  There  is  no  morbid  change  in 
the  aflfective  sphere.  The  patient  reacts  in  a  normal  man- 
ner to  external  influences.  In  his  conversation  he  speaks 
calmly  and  reasonably,  so  that  nothing  unusual  can  be 
noticed  in  him.  But  when  his  fixed  delusions  are  touched 
upon,  he  becomes  lively  and  agitated,  and  if  they  are 
slighted  or  contradicted,  violent  emotions  may  be  called 
forth.  A  few  words  may  suffice  to  upset  the  patient's 
mental  balance. 

The  chief  criterion  for  the  diagnosis  of  secondary 
insanity  are  the  fixed  delusions.  Delusions  are  desig- 
nated as  fixed  when  they  are  no  more  supported  and 
nourished  by  morbid  changes  of  the  affective  state  or  by 
hallucinations,  but  persist,  although  these  causative  fac- 
tors of  delusions  have  ceased  long  ago  (Ch.  30,  p.  59). 
With  the  establishment  of  fixed  delusions  permanent 
feeble-mindedness  has  been  proved.  Aside  from  his 
fixed  delusions  the  patient's  judgment  is  quite  normal, 
and  he  may  even  be  very  intelligent,  but  in  the  province 
of  these  unchangeable  wrong  notions  he  is  entirely  devoid 
of  the  slightest  reasoning  power.  They  occupy,  as  it 
were,  an  isolated  position  in  his  mentality  and  exert  no 
influence  on  his  character  and  conduct.  He  performs 
acts  which  are  strikingly  incompatible  with  and  contra- 
dictory to  his  insane  ideas.  While  a  primarily  insane  pa- 
tient possessed  by  the  delusion  of  being  heir  to  the  throne 
refrains  from  any  vulgar  work  considering  it  below  his 


SPECIAL  PATHOLOGY  183 

Royal  dignity,  the  secondarily  insane  patient  harboring 
the  same  idea  is  not  ashamed  of,  and  does  not  abstain 
from,  the  most  humble  labor.  He  does  not  feel  the  con- 
tradiction between  his  low  occupation  and  his  high  no- 
tion of  being  a  king.  This  inconsistency  indicates  that 
mental  enfeeblement  has  resulted  from  the  preceding  pri- 
mary insanity.  Only  when  the  patient  is  provoked,  when 
he  is  reproached  for  doing  w^ork  unbecoming  a  king,  he 
abandons  it  and  conducts  himself  in  conformity  with  his 
delusion.  But  his  dignified  bearing  does  not  last  any 
longer  than  the  emotion  produced  by  the  provocation. 
When  after  a  comparatively  short  time  the  emotion  has 
subsided,  he  resumes  the  work  unworthy  of  His  Royal 
Highness. 

The  volitional  activity  is  entirely  normal  in  all  mat- 
ters not  relating  to  the  contents  of  the  insane  ideas.  But 
when  the  patient  has  been  exasperated  through  allusion 
to  his  delusions,  he  displays  great  energy  and  is  even  apt 
to  perform  dangerous  acts. 

Differential  Diagnosis.  A  secondarily  insane 
patient,  while  not  in  a  stage  of  exacerbation  (see  Prog- 
nosis), can  easily  be  distinguished  from  a  paranoiac  in 
the  first  attack.  It  happens,  however,  that  primary  in- 
sanity makes  a  standstill  and  then  recurs  (p.  181).  The 
following  paranoiic  attack  differs  very  little  from  sec- 
ondary insanity  if  the  first  attack  has  resulted  in  some 
mental  enfeeblement  with  fixed  delusions.*  The  main 
differentiating  feature  is  that  in  recurrent  paranoia  new 
delusions  arise,  which  is  not  the  case  in  secondary  insanity 
unless  it  becomes  aggravated  by  an  exacerbation.  Sec- 
ondary insanity  in  a  stage  of  exacerbation  is  equivalent 
to  recurrent  paranoia  associated  with  mental  enfeeble- 
ment which  has  been  brought  about  by  a  previous  attack. 


i84  PSYCHE 

Course  and  Prognosis.  There  is  no  recovery  from 
secondary  insanity.  Sometimes  the  mental  disease  makes 
even  further  progress  through  the  arising  of  exacerba- 
tions with  new  delusions.  After  the  cessation  of  such  an 
acute  attack  the  recent  delusions  remain  permanent,  be- 
come fixed.  In  this  way  several  groups  of  fixed  delu- 
sions, belonging  to  different  attacks  and  mutually  inde- 
pendent, are  established.  Now  one  system  of  delusions 
occupies  the  patient's  mind,  now  another.  A  patient  who 
has  gone  through  many  exacerbations,  retaining  new  de- 
lusions after  every  attack,  may  be  entirely  confused  and 
unintelligible  to  the  observer. 

Therapy.  The  possibility  of  the  disease  making 
further  progress  is  important  in  the  treatment  of  sec- 
ondary insanity.  As  a  rule,  the  patients  are  harmless 
and  fit  for  work.  They  may,  therefore,  be  employed  in 
the  asylum  in  a  useful  manner.  When  an  exacerbation 
arises,  they  become  again  distrustful  and  discontent  and 
are  to  be  treated  like  primarily  insane  patients. 

Secondarily  insane  patients  may  be  left  in  private 
care.  The  mental  faculties  that  have  remained  intact 
are  to  be  fostered  with  special  attention  and  stimulated 
judiciously  by  appropriate  occupation.  It  is  not  neces- 
sary to  exclude  the  patients  from  society.  Their  rela- 
tives must  be  instructed  to  avoid  discussing  in  conversa- 
tion anything  that  could  be  construed  as  bearing  upon 
the  contents  of  the  fixed  delusions. 

When  provoked  secondarily  insane  patients  may 
commit  criminal  acts  and  thus  come  into  conflict  witli 
the  Penal  Code.  They  are,  then,  to  be  deemed  irre- 
sponsible in  the  same  way  as  at  the  time  when  their  delu- 
sions were  still  supported  by  hallucinations. 


SPECIAL  PATHOLOGY  185 

Chapter  LXXVIL 
DELIRIUM. 

Symptom-complex.  Great  excitability  of  the  cen- 
tral nervous  system  forms  the  basis  of  many  symptoms 
of  delirium.  The  affective  state  is  marked  by  consider- 
able fluctuations,  sadness,  cheerfulness,  anger,  fright, 
etc.,  alternating  frequently.  The  ideational  sphere  is 
characterized  by  hallucinations  in  several  senses,  by  in- 
coherence and  flight  of  ideas.  Consciousness  is  dis- 
turbed to  a  greater  or  lesser  degree.  The  frequency  of 
the  volitional  manifestations  and  the  energy  are  in- 
creased. In  the  somatic  sphere  high  fever  is  often  pres- 
ent. The  patient  impresses  the  observer  as  being  danger- 
ously ill.  He  takes  very  little  nourishment,  and  the 
assimilation  is  greatly  reduced.  The  strength  of  the  pa- 
tient decreases  perceptibly.  Sleep  is  disturbed  or  lack- 
ing altogether,  but  also  soporous  conditions  are  met 
with. 

Clinical  Picture.  The  patient  is  greatly  agitated. 
Even  when  lying  in  bed,  too  weak  to  keep  himself  erect, 
he  is  not  quiet  for  a  moment,  but  is  continually  tossing 
about.  His  consciousness  is  benumbed.  In  his  frequent 
soliloquies  he  reveals  bewilderment.  When  spoken  to,  he 
answers  but  irrationally  or  not  at  all.  He  is  not  clear 
about  time  and  place,  does  not  recognize  his  surroundings 
— disorientation — and  presents  the  symptom  of  con- 
founding persons,  believing  to  see  old  acquaintances  in 
people  he  has  never  known.  The  patient's  confusion  is 
still  more  enhanced  by  manifold  hallucinations  which 
produce  strong  emotions.  Now  he  laughs,  now  he  cries 
or  ejaculates  exclamations  of  terror. 

The  movements  of  the  patient  are  rapid,  forceful. 


i86  PSYCHE 

uncertain,  so  that  he  often  hurts  himself.  A  peculiar 
symptom  is  falling  down  which  appears  to  be  intentional. 
It  happens  that  the  patient  stands  quietly  for  some  time. 
Suddenly  he  drops  to  the  ground,  the  body  rigid,  on  his 
face  or  on  the  back,  receiving  considerable  injuries. 

The  energy  is  sometimes  very  much  increased.  A 
delirious  patient  so  feeble  that  he  has  to  be  kept  in  bed, 
may  unexpectedly  leave  it  and  rush  towards  the  door 
intent  upon  escaping.  By  a  sudden  jump  through  the 
window  he  may  end  his  life.  The  patient's  death  in  such 
a  case  is  not  due  to  suicidal  intention,  but  to  confusion 
or  to  the  compelling  force  of  terrifying  hallucinations. 
A  delirious  patient  is  also  dangerous  to  others.  He  may 
assault  any  one  coming  near  him  in  a  reckless  manner, 
making  use  of  any  murderous  instrument. 

A  patient  in  delirium  usually  rejects  nourishment. 
He  would  even  eject  food  introduced  into  his  mouth.  At 
times  he  hastily  swallows  down  something.  The  refusal 
of  food  is  aggravated  by  fever  which  is  very  common  in 
delirium.  The  appearance  of  the  patient  is  that  of  one 
seriously  ill.  His  face  is  somewhat  flushed,  his  eyes  are 
without  lustre.  Now  and  then  he  perspires  abundantly. 
The  lack  of  sleep  and  of  nourishment,  the  fever,  and  the 
restlessness  contribute  to  reduce  the  patient's  strength 
perceptibly  and  rapidly. 

The  deliria  are  usually  of  toxic  origin.  They  are 
caused  by  chronic  poisoning,  as  through  alcohol,  mor- 
phine, cocaine,  etc.,  or  by  the  toxines  of  the  acute  infec- 
tious diseases.  In  some  cases  of  delirium  no  direct  toxic 
factor  is  demonstrable.  Epileptic  patients  even  without 
indulging  in  intoxicants  are  subject  to  deliria  representing 
psychical  equivalents    (p.   243-244)   of  the  epileptic  at- 


SPECIAL  PATHOLOGY  187 

tacks.  A  peculiar  delirium  of  unknown  origin  is  the  de- 
lirium acutum  which  will  be  treated  later  (p.  263). 

Differential  Diagnosis.  Delirium  sometimes  re- 
sembles maniacal  excitement.  But  a  maniac's  cheerful 
mood  is  rather  lasting,  while  an  eventual  cheerfulness  in 
delirium  disappears  quickly.  The  consciousness  is  hazy 
in  delirium,  but  clear  in  mania.  A  patient  in  maniacal 
excitement  has  a  rather  florid  countenance  and  a  healthy 
appearance,  a  delirious  patient  looks  seriously  ill,  hectic. 
Refusal  of  food  does  not  occur  in  mania,  but  is  frequent 
in  delirium.  It  happens,  indeed,  that  a  maniac  does  not 
take  food.  But  this  is  due  to  intense  excitement  which 
renders  the  patient  unable  to  carry  out  the  movements 
necessary  for  taking  food.  When  in  such  a  case  the  food 
is  put  into  his  mouth  or  he  is  otherwise  helped,  he  swal- 
lows it  even  with  eagerness.  A  delirious  patient  rejects 
the  food  even  when  it  is  handed  to  him.  He  spits  it  out 
when  it  is  put  into  his  mouth. 

It  is  sometimes  very  difficult  to  differentiate  delirium 
from  hallucinatory  insanity.  Consciousness  in  the  lat- 
ter psychosis,  even  when  the  hallucinations  are  ever  so 
vivid  and  varied,  is  never  impaired  to  such  an  extent  as  in 
delirium.  The  strength  of  the  hallucinating  patient  does 
not  sink  as  rapidly  as  that  of  a  patient  in  delirium.  Fever 
is  often  present  in  delirium,  but  is  absent  in  hallucinatory 
insanity.  The  anamnesis  may^also  help  to  clear  up  the 
diagnosis.  In  a  patient  who  is  suffering  from  an  acute 
infectious  disease,  or  in  an  epileptic,  delirium  is  to  be 
assumed  rather  than  hallucinatory  insanity. 

Course  and  Prognosis.  The  duration  of  delirium 
is  short.  It  varies  between  a  few  hours  and  4-6  weeks. 
Usually  delirium  terminates  in  recovery,  but  many  a  pa- 
tient succumbs  directly  to  the  deleterious  effects  of  the 


1 88  PSYCHE 

mental  disorder  notwithstanding  the  best  care  and  cir- 
cumspection in  the  treatment.  The  physician  must  there- 
fore be  cautious  in  the  prognosis  of  deHrium. 

Therapy.  Dehrious  patients  require  careful  watch- 
ing. They  must  be  guarded  against  self -in  jury.  Spe- 
cial attention  is  to  be  paid  to  the  nutrition  of  the  patients. 
When  their  strength  sinks  rapidly,  artificial  feeding  must 
be  instituted  without  delay  by  introducing  food  per  rec- 
tum or  through  the  stomach  tube.  Only  nutrient  liquids, 
easy  of  absorption,  are  to  be  used  for  this  purpose.  It  is 
necessary  to  avoid  giving  too  much  food. 

For  the  sake  of  saving  the  patient's  strength  and  of 
preventing  exhaustion,  medicaments  are  necessary  to  quiet 
him.  Before  administering  hypnotic  drugs  heart  and 
lungs  must  be  carefully  examined.  Otherwise  it  may 
happen  that  after  taking  2  grams  of  chloral  hydrate,  for 
instance,  the  patient  falls  into  a  sleep  from  which  he  does 
not  awake.  An  appropriate  way  of  giving  medicines  is 
hypodermic  injection  which  is  less  difficult  than  medica- 
tion per  OS.  Strict  disinfection  of  skin  and  hypodermic 
syringe  is  necessary,  as  an  eventual  phlegmon  may  easily 
lead  to  gangrene  because  of  the  weakened  condition  of 
the  patient.  A  sedative  effect  on  very  restless  patients  is 
derived  from  wet  packings  and  protracted  warm  baths. 
But  these  procedures  can  be  employed  only  with  great 
difficulty  on  account  of  the  resistance  of  the  patients. 


SPECIAL  PATHOLOGY  189 

Chapter  LXXVIIL 

SECONDARY  FEEBLE=MINDEDNESS,  SECONDARY 
DEMENTIA. 

Secondary  dementia  is  the  result  of  a  psychosis.  It 
shows  many  gradations  of  which  the  hghter  ones  may 
be  designated  as  secondary  feeble-mindedness. 

In  some  instances  a  diminution  of  mental  capacity 
is  perceptible  only  to  the  intimate  acquaintances  of  the 
patient,  while  other  people  would  hardly  recognize  in 
him  any  mental  weakness.  In  other  instances  every 
mental  faculty  of  the  patient  has  been  annihilated.  Be- 
tween these  two  extremes  there  are  many  more  or  less 
grave  forms  of  secondary  dementia. 

Agitated  and  apathetic  dementia  have  been  distin- 
guished. Some  patients  are  lively  and  manifest  a  cer- 
tain restlessness,  others  are  very  quiet  and  mute.  Which 
of  these  two  forms  will  be  present,  depends  upon  the 
original  psychosis.  In  secondary  dementia  resulting  from 
mania  the  patient  would,  from  time  to  time,  fall  into  a 
state  of  excitement,  of  much  lower  intensity  though  than 
that  of  the  primary  mania.  If  the  dementia  is  the  out- 
come of  a  psychosis  in  which  excitative  states  are  rare, 
it  shows  the  apathetic  character. 

Symptom-complex.  There  is  an  impairment  of 
the  affective  sphere  ranging  from  a  diminution  of  the 
affective  tones  to  complete  obliteration  of  all  feeling 
(Ch.  17,  p.  36).  Similar  conditions  prevail  in  the  idea- 
tional province.  The  production  of  ideas  is  only  les- 
sened in  some  instances,  in  others  hardly  any  idea  arises 
in  the  patient's  consciousness,  so  that  the  whole  treasure 
of  experiences  stored  up  in  his  brain  seems  to  have  been 
wiped   out  by   the   preceding  psychosis.      Memory   and 


190  PSYCHE 

power  of  understanding  are  more  or  less  reduced,  in 
aggravated  cases  both  functions  have  been  abolished.  As 
to  the  activity  of  the  will  there  is  in  agitated  dementia  an 
increase  of  the  frequency  of  volitional  manifestations, 
and  a  decided  diminution  of  the  energy  of  persistence 
(pp.  84,  86).  In  apathetic  dementia  both  are  decreased. 
The  vegetative  functions  proceed,  as  a  rule,  normally. 
The  physical  condition  of  the  patient  is,  therefore, 
usually  satisfactory.  Yet  they  readily  acquire  other  dis- 
eases, as  tuberculosis. 

Clinical  Picture.  The  patient  is  constantly  in  a 
mood  of  indifference  and  indolence.  He  takes  no  inter- 
est in  his  surroundings  and  is  very  little  concerned  about 
his  own  affairs  and  the  welfare  of  his  nearest  relatives. 
In  his  speech  and  conduct  he  betrays  poverty  of  ideas. 
The  deficiency  of  his  memory  shows  itself  in  his  inability 
to  remember  especially  events  antedating  his  acute  mental 
malady.  He  has  not  progressed  with  time.  When  ques- 
tioned in  which  year  he  is  living,  he  would  frequently 
name  another  than  the  current  year,  generally  the  one  in 
which  he  first  became  mentally  ill.  If  a  demented  patient 
is  frequently  overheard  to  mention,  in  his  soliloquies,  a 
certain  year,  the  assumption  is  justified  that  his  mental 
derangement  has  commenced  in  that  year. 

In  agitated  dementia  the  patient  manifests  some 
excitement.  He  walks  up  and  down  the  room,  tugs  at 
his  clothes,  pulls  and  twists  his  hair,  and  handles  any- 
thing he  can  get  a  hold  of.  All  his  manipulations  are  to 
no  purpose.  He  utters  often  incomprehensible  words 
and  broken  sentences.  Mechanically  he  repeats  one  and 
the  same  phrase  for  hours  (verbigeration).  In  apathetic 
dementia  the  patient  is  quiet,  speaks  very  little,  and  per- 
forms but  few  volitional  acts. 


SPECIAL  PATHOLOGY  191 

The  capacity  of  understanding  is  markedly  dimin- 
ished. The  patient  does  not  comprehend  the  simplest 
questions  and  gives  very  superficial  answers.  He  has  no 
clear  conception  of  time  and  place.  He  leads  more  or 
less  a  mechanical  life,  according  to  the  regulations  prev- 
alent at  the  asylum.  Left  to  his  own  guidance,  he  would 
be  unable  to  observe  any  order  of  affairs.  He  would  eat 
and  drink  to  excess  and  at  improper  times,  he  would 
swallow  harmful  food,  gulp  down  fluids  which  are  too 
hot,  etc.  He  would  neglect  the  cleanliness  of  his  body, 
he  would  remain  in  bed  for  days,  not  leaving  it  even  to 
relieve  nature,  and  then  again  he  would  not  go  to  bed  for 
several  days.  He  would  expose  himself  to  cold,  insuffi- 
ciently clad,  and  would  sit  in  the  direct  sunlight  for  hours. 
He  is  dependent  for  his  welfare  upon  others,  being  help- 
less when  left  alone. 

The  vegetative  functions,  as  appetite,  digestion  and 
assimilation  of  food,  and  sleep,  are  normal  in  agitated 
dementia.  In  apathetic  dementia  disturbances  of  the 
vegetative  processes  occur,  but  they  are  brought  about 
only  by  the  apathy.  Owing  to  continued  lack  of  muscular 
movements  the  circulation  is  sluggish.  The  lower  ex- 
tremities become  swollen,  the  face  looks  bloated.  The 
lack  of  physical  exercises  causes  heart  weakness.  These 
evils  can  be  obviated  by  proper  care,  a  proof  that  they 
are  due  to  the  apathy,  not  to  the  dementia  as  such. 

Sometimes  the  question  is  to  be  decided  how  long 
a  patient  has  been  demented,  whether  his  dementia  has 
existed  since  earliest  youth,  or  has  commenced  at  a  later 
age.  To  arrive  at  a  decision  fragments  or  remnants  of 
a  former  education  are  to  be  sought  after.  Sometimes 
the  patient  surprises  his  observer  by  uttering  Latin  or 
Greek  words  or  some  scientific  technical  terms.     After 


192  PSYCHE 

the  detection  of  such  fragments  of  former  schoohng  and 
learning  there  is  no  doubt  that  the  patient  was  in  full 
possession  of  his  mental  faculties  at  least  until  the  age 
when  higher  educational  accomplishments  are  attained. 

Differential  Diagnosis.  It  is  possible  to  con- 
found secondary  with  primary  dementia.  But  the  an- 
amnesis reveals  that  the  former  has  been  preceded  by  a 
psychosis,  the  latter  by  some  other  acute  disease.  In  the 
absence  of  an  anamnesis,  the  differentiation  can  be  made 
only  by  a  somewhat  extended  observation  of  the  case. 
In  primary  dementia  the  patient  improves  quite  rapidly, 
while  in  secondary  dementia  even  after  months  no  change 
in  the  patient's  condition  is  noticeable. 

Course  and  Prognosis.  Secondary  dementia  is 
incurable.  The  mental  condition  of  the  patients  does  not 
improve.  On  the  contrary,  observation  of  the  patients, 
extending  over  many  years,  shows  that  from  time  to 
time  something  of  the  remains  of  mental  faculty  crumbles 
off,  the  dementia  thus  gradually  progressing.  Unlike 
other  psychoses,  for  instance  delirium,  dementia  as  such 
never  leads  to  death.  If  no  intercurrent  disease  super- 
venes, demented  patients  may  attain  old  age. 


Chapter  LXXIX. 

PRIMARY   MENTAL   WEAKNESS,   PRIMARY 
CURABLE   DEMENTIA. 

After  grave  infectious  diseases  or  abundant  loss  of 
blood  the  patients  may  remain  in  a  state  of  great  mental 
weakness.  Although  the  fever  has  ceased,  and  appetite, 
digestion,  assimilation,  and  sleep  are  normal  again,  their 
vigor  of  mind  is  but  slowly  restored.    The  psychical  func- 


SPECIAL  PATHOLOGY  193 

tions  continue  to  be  sluggish  and  defective,  and  thus  the 
patients  create  the  impression  of  being  demented.  They 
are  indifferent  to  everything  and  everybody  around  them 
and  poor  in  ideas.  The  memory  is  debihtated,  the  fre- 
quency of  vohtional  manifestations  is  diminished,  the 
energy  is  lowered.  The  vegetative  functions,  however, 
proceed  fairly  well. 

This  symptom  complex,  coinciding  with  that  of  sec- 
ondary dementia,  is  founded  solely  upon  a  state  of  gen- 
eral exhaustion  in  which  the  mental  faculties  have  been 
more  unfavorably  affected  than  the  vegetative  functions, 
so  that  the  recuperation  of  the  vigor  of  mind  has  been 
rendered  more  difficult  and  requires  more  time  than  the 
restoration  of  the  general  health. 

Course  and  Prognosis.  Primary  feeble-minded- 
ness  ordinarily  ends  in  restitutio  ad  integrum  and  is  of 
comparatively  short  duration.  It  is  possible,  however, 
that  recovery  does  not  ensue  and  the  dementia  remains 
permanent.  But  such  a  termination  is  to  be  assumed 
only  after  the  mental  weakness  has  persisted  unchanged 
for  a  very  long  time,  for  many  months  following  the 
acute  disease  by  which  it  has  been  produced. 

Differential  Diagnosis.  The  anamnesis  is  of 
chief  importance  in  the  recognition  of  primary  mental 
weakness.  It  shows  that  a  severe  acute  disease  has  re- 
cently preceded.  But  also  through  mere  observation  of 
the  case  primary  and  secondary  dementia  can  be  distin- 
guished from  one  another.  In  primary  dementia  some 
improvement  is  already  noticeable  after  a  short  time,  one 
or  two  weeks.  The  patient  shows  more  interest  for  his 
surroundings,  produces  more  ideas,  displays  pleasure  at 
the  visit  of  a  friend,  etc.,  while  in  the  beginning  he  was 
indifferent  to  everything.     In  secondary  dementia,  how- 


194  PSYCHE 

ever,  even  after  a  year  no  change  in  the  patient's  mental 
condition  is  perceptible. 

Therapy.  Owing  to  the  favorable  progress  of  the 
vegetative  functions  the  treatment  does  not  offer  much 
difficulty.  The  patient  should  not  receive  too  much  al- 
cohol as  a  stimulant.  In  intellectual  respect  care  must  be 
taken  that  the  patient  is  not  overtaxed  in  the  least.  When 
he  begins  to  manifest  some  interest  in  his  surroundings, 
to  show  that  he  is  not  indifferent  to  the  call  of  a  friend, 
etc.,  relatives  and  attendants  should  not  think  that  they 
ought  to  animate  and  exhilerate  him  as  much  as  possible, 
to  allow  him  to  receive  as  many  friends  as  he  would  wish, 
to  let  him  hear  all  kinds  of  news,  etc.  On  the  contrary, 
it  is  necessary  to  be  reserved.  The  patient's  mental  pow- 
ers must  be  spared  and  not  tasked  much. 


SECTION  11. 

MENTAL  DISEASES   DATING   FROM   EAR- 
LIEST CHILDHOOD,  IDIOCY,  CRETINISM 


Chapter  LXXX. 

DEFINITION,    CLASSIFICATION,    AND     PHYSICAL 
STIGMATA  OF  IDIOCY. 

Individuals  who  have  been  affected  with  cerebral 
diseases  either  in  foetal  Hfe  or  as  very  young  children 
and  in  consequence  thereof  are  afflicted  with  mental  de- 
fects traceable  to  early  childhood  are  designated  as  idiots. 

A  young  child  may  acquire  an  acute  psychosis  in  the 
same  way  as  an  adult.  When  the  sanity  of  the  child  is 
not  fully  restored,  but  permanent  feeble-mindedness, 
more  or  less  pronounced,  results  from  the  psychosis,  the 
child  becomes  an  idiot.  In  idiocy,  therefore,  we  are  deal- 
ing with  deficiencies  of  the  mind,  not  with  acute  psycho- 
pathological  processes.  The  mental  defects  remaining 
after  acute  psychoses  of  adults  constitute  the  clinical  pic- 
ture of  secondary  dementia  (Ch.  78,  p.  189),  acute  psy- 
choses of  young  children,  however,  produce  idiocy  unless 
complete  recovery  takes  place. 

Idiocy  presents  itself  in  many  gradations  which  have 
been  divided  into  two  principal  classes,  namely  superior 
idiocy  and  inferior  idiocy,  the  faculty  of  speech  furnish- 
ing the  dividing  line.  Idiots  who  do  not  speak  at  all  or 
very  little  have  been  called  inferior  idiots,  those  who 
master  the  language  perfectly  or  almost  so  have  been 


196  PSYCHE 

designated  as  superior  idiots  or  imbeciles.  Among  the 
latter  are  also  counted  individuals  who  manifest  a  single 
mental  defect  and  are  otherwise  normal,  for  instance, 
patients  affected  with  moral  insanity,  querulous  in- 
sanity, originary  insanity,  sexual  perversity.  Etiologi- 
cally  cretinism  has  been  separated  from  idiocy.  Cretin- 
ism comprises  a  sum  of  physical  and  mental  defects  at- 
tributable to  a  definite  territorial  cause,  i.  e.,  to  conditions 
of  the  soil  prevailing  in  a  certain  region  (p.  214).  Every 
cretin  is  an  idiot,  but  not  every  idiot  is  a  cretin. 

In  somatic  respect  some  idiots  exhibit  physical  signs 
from  which  their  idiocy  may  be  inferred.  Especially  the 
configuration  of  the  skull  is  apt  to  betray  idiocy.  Macro- 
cephalia,  microcephalia,  and  obliquity  of  the  skull  are 
met  with  in  idiots.  These  anomalies  are  sometimes  due 
to  premature  synostoses  of  cranial  sutures.  Macroce- 
phalia  is  brought  about  by  hydrocephalus  in  early  child- 
hood or  by  meningitis  with  abundant  secretion  of  cere- 
brospinal fluid.  The  brain  is  smaller  than  normally  in 
microcephalia.  If  it  appears  larger,  this  is  due  to  a  wid- 
ening of  the  cerebral  ventricles  through  hydrocephalus 
inter  nus. 

The  features  of  the  face,  quite  normal  in  childhood, 
become  sometimes  irregular  at  the  age  of  puberty.  A 
disproportion  arises  between  the  facial  and  cerebral  parts 
of  the  skull,  producing  an  unsightly  appearance,  which 
may  be  still  more  enhanced  by  the  presence  of  a  large 
goitre. 

Impairment  of  the  general  growth  of  the  body  oc- 
curs in  idiocy ;  some  idiots  remain  dwarfs. 

Other  somatic  defects  met  with  in  idiots  consist  in 
motor  disturbances.  Some  idiots  are  affected  with  par- 
eses  or  even  with  complete  hemiplegia.     With  the  latter 


SPECIAL  PATHOLOGY  197 

motor  disturbance  there  is  usually  associated  an  asym- 
metry of  the  skull,  the  heterolateral  cranial  half  being 
smaller  than  the  homolateral.  An  eventual  autopsy  shows 
that  one  cerebral  hemisphere  is  reduced  in  size,  while  the 
cerebellar  hemisphere  of  the  same  side  is  either  smaller 
or  larger  than  normally. 

Some  idiots  are  affected  with  epilepsy.  A  vicious 
circle  is  thus  established.  For  epilepsy  itself  reduces 
gradually  the  mental  faculties.  Epileptic  idiots  show, 
therefore,  a  progress  of  their  psychical  defects.  This 
can  be  recognized  when  there  is  opportunity  to  observe 
such  patients  in  their  early  youth  and  at  a  later  age. 

In  some  cases  of  idiocy  the  autopsy  reveals  pro- 
nounced loss  of  cerebral  substance,  porencephalia. 


Chapter  LXXXI. 
INFERIOR  IDIOTS. 

The  inferior  idiots  are  characterized  by  great  im- 
pairment of  speech.  All  their  psychical  faculties  are 
more  or  less  defective.  In  the  affective  sphere  they  re- 
semble small  children.  They  are  very  irritable,  weep  at 
the  slightest  cause,  and  fall  readily  into  despondency. 
They  are  devoid  of  the  finer  gradations  of  feeling  so 
numerous  in  well-developed  individuals.  They  lack  the 
wealth  of  emotions  of  normal  persons,  being  capable 
only  of  the  extreme  emotional  manifestations,  such  as 
unbounded  exultation,  pain,  wrath,  despair,  etc.  Of 
ethical  notions,  of  conceptions  of  filial  love,  decency, 
honor,  duty,  there  is  no  vestige  in  them.  They  are  want- 
ing even  in  such  expressions  of  the  affective  sphere  as 


198  PSYCHE 

are  met  with  in  some  animals,  for  instance  gratitude, 
attachment,  faithfulness. 

The  power  of  understanding  is  considerably  les- 
sened. The  intelligence  of  the  inferior  idiots  is  so  low 
that  they  are  unable  to  repeat  words  when  urged  to  do  so. 
They  hear  sounds,  for  it  is  possible  to  demonstrate  that 
they  are  not  deaf,  yet  they  do  not  retain  in  mind  the 
auditory  images  necessary  for  speech.  Some  inferior 
idiots  learn  to  know  the  names  of  things.  Requested  to 
bring  a  certain  object  they  would  fetch  it,  but  they  can- 
not repeat  the  name  of  the  object  when  it  is  pronounced 
before  them,  and  this  not  because  they  are  affected  with 
paralysis  of  the  motor  organs  of  speech,  but  because  they 
lack  the  energy  and  understanding  needed  for  an  attempt 
to  repeat  words. 

The  inferior  idiots  speak,  after  the  manner  of  small 
children,  in  infinitives. 

A  remarkable  symptom  of  inferior  idiocy  is  the  want 
or  defectiveness  of  self-consciousness.  A  child  learns 
quite  early  to  distinguish  its  own  person  from  the  ex- 
ternal world,  i.  e.,  it  acquires  self -consciousness  (p.  28). 
It  arrives  at  knowing  the  little  word  "L"  Small  children 
when  asked  who  has  done  this  or  that  would  reply  with 
their  name  instead  of  saying  "1."  As  they  advance  in 
intelligence,  they  begin  to  answer  with  *T,"  showing 
hereby  that  they  have  reached  a  fair  degree  of  self -con- 
sciousness. Many  inferior  idiots  remain  on  the  first 
stage,  speaking  of  themselves  in  the  third  person. 

The  low  intelligence  of  inferior  idiots  becomes  very 
obvious  by  their  failure  to  recognize  and  shun  evils  which 
they  have  experienced  a  short  while  ago.  The  inferior 
idiot  will  touch  the  red  hot  coal  which  has  just  given  him 
a  painful  burn. 


SPECIAL  PATHOLOGY  199 

The  memory  of  inferior  idiots  is,  as  a  rule,  as 
poor  as  their  intelHgence.  But  in  some  instances  it  is  re- 
markably good,  in  striking  contrast  with  the  other  mental 
faculties. 

In  the  volitional  sphere  the  inferior  idiots  display 
an  impulsive  character.  They  are  unable  to  control  them- 
selves. A  trifle  may  throw  them  into  great  agitation. 
Sometimes  they  would  run  about  wildly  in  the  room  or 
they  would  sit  and  constantly  make  rocking  movements. 
They  are  wavering,  fickle,  incapable  of  acting  with  de- 
sign and  deliberation.  When  they  accomplish  some  mis- 
chief, they  do  it  without  preconceived  intention.  Some- 
times, however,  they  exhibit  great  perseverance  in  the 
execution  of  certain  acts  (p.  85).  Some  idiots  have  a 
predilection  for  fire  and  may  hereby  cause  arson.  There 
is  nothing  specific  in  this  symptom.  Children,  too,  are 
fond  of  fire;  they  like  to  light  matches.  Characteristic 
pyromania  is,  therefore,  not  to  be  ascribed  to  inferior 
idiots.  The  entire  volitional  sphere  of  inferior  idiots  is 
characterized  by  unbridled  passions. 

It  is  chiefly  the  inferior  idiots  who  exhibit  the  phy- 
sical stigmata  and  other  somatic  disturbances,  such  as 
asymmetry  of  the  skull,  pareses,  epilepsy,  etc.,  which 
have  been  mentioned  in  the  preceding  chapter. 


Chapter  LXXXII. 
SUPERIOR   IDIOTS,   IMBECILES. 

The  superior  idiots  or  imbeciles  differ  from  the  in- 
ferior idiots  by  the  faculty  of  speech.  As  a  rule  they 
possess  an  adequate  knowledge  of  language. 

In  the  affective  sphere  the  extreme  emotional  mani- 


200  PSYCHE 

festations  prevail.  The  imbeciles  are  very  excitable, 
readily  susceptible  of  grief  and  anger.  Such  emotions 
reach  extraordinary  intensity.  A  trifle  makes  the  im- 
beciles chafe  with  fury.  The  emotions  last  unusually 
long.  The  imbeciles  persist  in  an  emotion  of  fierce  wrath 
or  deep  sadness  for  hours  and  days.  In  such  a  frame  of 
mind  they  are  apt  to  commit  dangerous  acts.  A  good 
many  cases  of  suicide  are  to  be  ascribed  to  imbecility. 

There  are  no  marked  defects  in  the  ideational  sphere. 
On  the  contrary,  some  imbeciles  are  endowed  with  an 
excellent  memory  and  are  thus  enabled  to  acquire  a  great 
wealth  of  experiences  which  they  have  readily  at  their 
disposal  (pp.  62-63).  But  the  intelligence  of  the  im- 
beciles is  defective  and  their  memory  is  one-sided.  It 
works  mechanically  without  selection,  retaining  the  en- 
tirely insignificant  things  just  as  well  as  the  most  im- 
portant ones.  The  former  would  not  impress  themselves 
on  a  memory  which  is  aided  by  a  good  understanding 
and,  therefore,  capable  of  separating  the  things  to  be  kept 
from  those  to  be  cast  aside  as  of  no  value. 

Owing  to  their  marvelous  memory,  many  superior 
idiots  are  not  recognized  as  such  in  school,  but,  on  the 
contrary,  are  considered  to  be  very  gifted  pupils.  This 
mistake  occurs  especially  when  they  are  somewhat  good- 
natured,  not  obstinate,  and  their  irascibility  is  slight.  A 
closer  examination,  however,  reveals  that  the  talented 
imbeciles  lack  the  proper  understanding  of  what  they 
have  studied,  that  they  have  learned  everything  in  a  me- 
chanical way,  by  heart,  and  reproduce,  like  a  dictionary, 
other  people's  opinions  and  judgments  which  are  always 
at   their    disposal    because    of   their    unfailing   memory 

(p.  63). 

Ordinarily,   however,   the  education  lays  bare  the 


SPECIAL  PATHOLOGY  201 

mental  defectiveness  of  the  imbeciles.  Imbecile  children 
cannot  adapt  themselves  to  order  and  rule,  cannot  bear 
censure,  much  less  punishment.  When  they  are  chastised, 
they  become  morose  and  stubborn,  do  not  know^  at  all 
what  is  going  on,  and  are  throw^n  into  emotions  of  blind 
rage  rendering  them  entirely  irresponsible.  It  is,  there- 
fore, not  conducive  of  good,  and  may  even  be  detri- 
mental, to  punish  imbecile  children.  When  they  are 
locked  up  for  ill  behavior,  they  are  apt  to  jump  out  of  the 
window  with  fatal  consequence. 

Imbeciles  are  incapable  of  imbibing  certain  concep- 
tions. Although  they  have  heard  of  duty,  honor,  friend- 
ship, filial  love,  etc.,  and  know  the  terms  well;  they  are 
not  fully  alive  to  them.  Normal  persons  having  acquired 
these  ethical  conceptions  through  education  and  associa- 
tion experience  a  certain  feeling,  are  put  into  a  certain 
mood,  whenever  their  mind  is  turned  upon  such  ethical 
subjects.  This  feeling  influences  all  their  actions.  Im- 
beciles, however,  lack  the  normal  affective  tones  accom- 
panying ethical  ideas  and  are,  therefore,  unable  to  con- 
form their  conduct  accordingly.  No  sense  of  duty  is 
inculcated  upon  their  mind  notwithstanding  the  best  edu- 
cation they  may  have  received.  They  cannot  abide  in  a 
situation  for  any  length  of  time,  but  crave  for  one  change 
of  occupation  after  the  other.  This  fickleness  and  un- 
steadiness in  desires  and  aims  appear  as  an  early  symp- 
tom. Imbecile  children  are  very  prone  to  run  away  at 
random.  They  escape  from  their  parents  or  simply  do 
not  return  home  from  school.  When  they  grow  older 
and  assume  situations,  they  do  not  keep  them  very  long. 
Suddenly  they  decamp  without  any  valid  reason.  At  the 
slightest  disagreeable  occurrence  they  abandon  their  work 
and  leave  without  any  regard  for  the  future.     Sometimes 


202  PSYCHE 

they  would  abide  by  one  occupation  for  a  longer  while, 
perhaps  for  a  year  or  so,  but  then  they  would  change  it 
too.  By  this  want  of  perseverance  imbecility  may  be 
recognized  even  in  such  cases  where  it  is  of  a  slight 
degree. 

Individuals  of  mental  inferiority  have  a  high  opinion 
of  themselves,  think  that  their  knowledge  is  great,  and 
are  self-complacent,  while  normal  persons,  even  if  they 
have  studied  very  much,  feel  with  a  sort  of  dissatisfac- 
tion and  are  conscious  that  they  know  little  in  compari- 
son to  what  they  still  have  to  learn. 

The  mental  inferiority  of  imbeciles  is  easily  recog- 
nized when  they  are  placed  in  a  situation  requiring  strict 
submission  to  prescribed  rules,  as  the  military  service. 
In  the  beginning  they  may  conduct  themselves  fairly 
well,  but  after  some  time  they  usually  become  unman- 
ageable. They  cannot  observe  the  requisite  discipline  and 
contract  punishment  after  punishment.  This,  however, 
fails  to  make  them  reform  their  ways  so  that  they  re- 
main incorrigible. 

When  however  imbeciles  are  living  in  simple  circum- 
stances, their  psychical  defectiveness  may  pass  unno- 
ticed. Should  such  individuals  become  subject  to  legal 
consideration,  it  would  be  very  difficult  for  the  medico- 
legal expert  to  prove  to  the  judge  that  he  is  dealing  with 
imbeciles.  Since  the  imbeciles  know  the  ethical  concep- 
tions only  by  name,  they  frequently  come  into  conflict 
with  the  Penal  Code  through  vicious  acts  committed  in 
emotional  fits,  through  offenses  against  morality,  through 
arson  executed  for  revenge,  etc. 

In  somatic  respect  the  imbeciles  usually  show  no 
deviation  from  the  normal.  In  some  cases  microcephalia 
is  met  with  or  an  excessive  thyroid  gland  with  cystic 


SPECIAL  PATHOLOGY  203 

degeneration.  The  whole  physiognomy  then  presents  a 
certain  pecuHarity  from  which  mental  inferiority  may  be 
inferred.  The  autopsy  of  imbeciles  sometimes  reveals  a 
diminution  of  the  weight  of  the  brain  or  a  division  of  one 
of  the  frontal  convolutions,  the  number  of  which  is  thus 
increased  to  four.  Defects  of  the  corpus  callosum  are 
found  in  some  cases. 

The  family  physician  having  convinced  himself  of 
the  imbecility  of  a  child  should  call  the  attention  of  the 
parents  to  its  mental  weakness  and  advise  them  to  regu- 
late its  education  accordingly.  An  imbecile  child  must 
not  be  overtasked.  Chastisement  for  disobedience  or  ill 
behavior  must  never  be  resorted  to.  For  severity  ren- 
ders the  imbecile  still  more  inflexible,  and  nothing  can 
be  accomplished  by  it.  Great  difficulty  is  encountered 
when  there  are  normal  children  in  the  family.  Removal 
from  home  of  the  imbecile  child  is  then  called  for  by  all 
means.  To  put  imbecile  children  into  an  asylum  for 
idiots  is  not  advisable.  For  in  such  an  institution  they 
are  liable  to  come  in  contact  with  inferior  idiots  which 
may  be  harmful  to  them.  Special  institutions,  therefore, 
ought  to  be  established  for  the  education  of  imbeciles. 

Imbecile  children  who  are  reared  in  their  own  homes 
grow  up  to  be  the  worst  elements  of  society.  The  family 
physician  ought  to  write  down  his  observations  of  an 
imbecile  child  in  the  form  of  documentary  records.  They 
may  become  very  useful  in  the  future  when  the  adult 
imbecile  is  summoned  to  court  to  answer  for  mis- 
deeds. 


204  PSYCHE 

Chapter  LXXXIII. 
MORAL    IDIOCY,    MORAL    INSANITY. 

Of  all  the  idiots  those  affected  with  moral  insanity 
have  sustained  the  least  impairment  of  mental  capacity. 
They  show  defects  only  in  moral  respect,  but  otherwise 
they  are  entirely  sane.  Formerly,  and  frequently  now- 
adays, the  moral  idiots  were  treated  as  criminals.  In- 
deed, it  is  very  difficult  to  draw  the  dividing  line  between 
those  suffering  from  moral  insanity  and  those  imbued 
with  moral  depravity.  Yet  the  differentiation  is  very 
important.  For  the  moral  idiots  are  unfortunate  patients 
who  could  not  justly  be  called  to  full  account  for  their 
misdeeds,  while  the  morally  depraved  individuals  are  re- 
sponsible. 

The  symptoms  of  moral  idiocy  relate  exclusively  to 
the  affective  sphere.  The  patients  are  not  influenced 
by  ethical  conceptions  in  the  same  way  as  are  normal 
persons.  The  actions  of  the  latter  do  not  depend  solely 
upon  understanding  and  reason.  Any  experience,  any 
idea  arising  in  consciousness,  any  recollection  of  former 
events  and  situations,  produces  in  normal  persons  certain 
alterations  of  the  affective  state,  certain  feelings.  Espe- 
cially ethical  ideas  are  accompanied  by  impressive  feel- 
ings. These  latter  more  than  anything  else  are  the  chief 
cause  of  normal  persons  acting  in  conformity  with  ethical 
principles.  There  are,  however,  individuals  in  whom 
ethical  ideas  fail  to  call  forth  the  feelings  they  normally 
give  rise  to.  Such  individuals  lack  the  foremost  incentive 
to  live  up  to  ethical  requirements.  Again  other  individ- 
uals receive  the  normal  affective  tones  from  actual  oc- 
currences, but  not  from  the  recollection  of  such  occur- 
rences.    Thus  they  grieve  very  much  at  a  restriction  of 


SPECIAL  PATHOLOGY  205 

their  freedom  and  promise  solemnly  to  desist  henceforth 
from  any  act  that  would  deprive  them  of  their  liberty. 
Notwithstanding  this  keen  feeling  aroused  by  actual  im- 
prisonment the  recollection  of  a  former  imprisonment 
leaves  them  entirely  indifferent,  being  devoid  of  the 
normal  affective  tone  associated  with  such  recollection. 
These  individuals  experience  no  feeling  when  they  see 
an  evil  approaching.  Not  before  they  are  in  the  midst 
of  the  painful  situation  do  they  feel  grieved  at  it.  Such 
patients  may  have  had  ever  so  many  severe  lessons,  the 
remembrance  thereof  will  not  keep  them  back  from  ac- 
tions which  they  know  very  well  will  make  them  undergo 
again  the  same  distressing  experiences. 

Moral  idiocy  is  characterized  by  ''zvant  of  educa- 
bility."  This  pathognomonic  feature  can  be  demonstrated 
in  all  cases  where  efforts  have  been  made  to  give  the 
individuals  in  question  a  good  education.  "Want  of 
educability"  is  no  meaningless  term,  no  vague  trait  that 
may  be  overlooked,  but  a  distinct  symptom  presenting 
itself  forcibly  to  the  attention  of  the  observer.  It  can  be 
.shown  that  a  boy,  morally  defective,  has  had  the  same 
education  as  his  sane  brothers  and  sisters,  has  been  cher- 
ished with  the  same  love,  has  been  censured,  not  to  say 
punished,  with  the  same  tender  caution,  or  even  that  in 
his  education  more  care  has  been  employed  than  with 
the  other  children  of  the  family.  Yet  all  attempts  to 
make  him  a  useful  member  of  society  have  remained 
without  avail,  while  his  brothers  and  sisters  have  ac- 
quired good  manners  and  character.  This  is  "want  of 
educability."  A  few  concrete  examples  will  illustrate  the 
matter  more  clearly.  A  prominent  psychiatrist  relates  a 
case  in  which  a  widow  had  taken  great  care  to  educate 
her  only  son,  who  was  very  naughty  and  insubordinate. 


2o6  PSYCHE 

But  all  her  endeavors  remained  unsuccessful.  Finally 
she  applied  to  the  director  of  a  well  conducted  educational 
institution.  He  consoled  the  worried  mother,  assuring 
her  that  he  would  get  the  better  of  her  unbridled  son. 
For  he  had  had  worse  cases  in  which  he  had  made  good 
men  out  of  refractory  boys  who  had  appeared  to  be  incor- 
rigible. He  took  the  boy  into  his  institution.  But  a  few 
months  later  he  wrote  to  the  unhappy  mother  that  he  had 
been  mistaken  in  her  son.  All  educational  means  to  im- 
prove his  character  would  be  futile.  He  had  no  concep- 
tion of  filial  affection,  honor,  duty,  etc.,  and  was  indif- 
ferent to  exhortation  and  reproach  and  insensible  to  pun- 
ishment. For  the  sake  of  the  other  pupils  he  would  have 
to  be  removed  from  the  institution  as  soon  as  possible. 
This  is  ''want  of  educability."  In  another  instance  a  boy 
of  a  good  family  had  been  expelled  from  several  schools 
and  had  subsequently  remained  unruly.  Finally  his  rela- 
tives succeeded  to  put  him  into  the  army  and  to  have  him 
assigned  to  a  regiment  the  colonel  of  which  was  a  friend 
of  the  family.  He  promised  to  educate  the  young  man. 
The  military  institution  has  excellent  educational  means 
at  its  disposal  and  subdues  many  a  young  man  apparently 
uneducable.  One  day  our  young  soldier  did  not  appear 
at  a  military  review.  The  colonel  sent  the  strict  order 
that  he  should  present  himself  forthwith.  This  per- 
emptory command  put  the  soldier  into  a  state  of  sullen 
stubbornness,  and  he  flatly  refused  to  obey  the  order, 
although  he  well  knew  the  imminent  punishment.  The 
incident  was,  however,  purposely  disregarded  and  he  was 
not  disciplined.  Later  he  stole  money  from  a  military 
office  and  was  punished  by  confinement  in  a  fortress.  He 
finished  his  military  service  without  showing  any  im- 
provement of  character.     Thereupon  an  uncle  of  his  ad- 


SPECIAL  PATHOLOGY  207 

vanced  the  statement  that  his  nephew  was  so  wicked  be- 
cause he  had  never  enjoyed  a  proper  education.  A  person 
of  his  disposition,  he  contended,  ought  to  be  dealt  with 
very  leniently.  He  took  his  ill-bred  nephew  into  his 
house,  proposing  to  make  a  good  man  of  him.  But  his 
attempts  at  education  remained  entirely  fruitless,  and  he 
finally  had  to  admit  that  his  nephew  was  lacking  the 
slightest  feeling  of  gratitude,  tact,  and  honor  and  was 
incorrigible.  Subsequently  the  young  man  was  com- 
mitted to  an  insane  asylum.  The  director  of  the  institu- 
tion declared  him  to  be  a  moral  idiot.  In  the  asylum  his 
conduct  was  very  satisfactory.  He  soon  opened  a  cor- 
respondence with  another  uncle  of  his,  sending  him  the 
nicest  letters.  The  uncle  began  to  remonstrate  with  the 
authorities  of  the  insane  asylum  on  the  detention  of  his 
nephew,  contending  that  there  is  no  such  mental  disorder 
as  moral  insanity.  He  was  finally  coaxed  by  the  gentle 
and  deferential  writings  of  his  nephew^  into  removing  him 
from  the  insane  asylum  and  taking  him  into  his  country 
home.  The  young  man  conducted  himself  fairly  well 
until  he  once  chanced  to  open  a  drawer  containing  money. 
Instantly  he  grabbed  the  cash  and  escaped  unnoticed.  He 
came  to  the  city  and  squandered  the  money  in  company 
with  the  servants  of  the  insane  asylum.  All  this  proves 
incontestably  that  the  recollection  of  the  many  adversi- 
ties and  penalties  had  failed  to  arouse  in  the  patient  any 
feeling  whatsoever.  This  is  "want  of  educability." 
When  this  symptom,  which  extends  over  many  years,  can 
be  established,  the  diagnosis  moral  idiocy  becomes  un- 
questionable. 

If  however  no  attempts  at  education  have  been  made, 
or,  on  the  contrary,  the  individual  in  question  has  grown 
up  in  pernicious  environment  and  has  been  corrupted,  it 


2o8  PSYCHE 

may  not  be  possible  to  differentiate  moral  idiocy  from 
moral  depravity.  A  slight  hint  may  perhaps  be  gained  by 
taking  into  consideration  that  even  uneducated  scamps 
and  criminals  have  some  sense  of  companionship  and 
friendship,  some  feeling  of  honor,  a  certain  willingness 
to  make  sacrifices  for  others,  while  the  moral  idiots  are 
devoid  even  of  such  traits. 

Want  of  the  affective  tones  which  accompany  ethical 
ideas  is  common  to  plain  imbecility  and  moral  idiocy. 
But  in  the  latter  it  forms  a  predominant  feature.  Be- 
sides, in  moral  idiots  intelligence  and  emotions  are  quite 
normal,  while  in  imbeciles  the  intelligence  is  deficient  and 
the  emotions  are  of  frequent  occurrence  and  of  extra- 
ordinary intensity  and  duration.  It  is  hardly  possible, 
but  practically  of  no  importance,  to  distinguish  moral 
idiocy  from  cases  of  imbecility  in  which  emotions  are 
little  prevalent  and  a  good  memory  hides  the  deficient 
intelligence.* 

As  to  the  management  of  moral  idiocy  it  must  be 
borne  in  mind  that  punishment  of  the  patients  is  not 
conducive  of  good. 


*  In  the  case  described  by  B.  S.  Talmey  (Medical  Record, 
Nov.  i6,  1907)  the  imbecile  traits  are  so  little  pronounced  that 
the  patient  is  to  be  considered  a  moral  idiot  rather  than  a  "high- 
grade  imbecile"  (superior  idiot).  This  case  is  mentioned  here 
because  of  the  remarkable  somatic  anomaly,  or  physical  stigma 
of  cryptorchism.  The  patient  had  only  one  testicle.  The  other 
could  not  be  found  even  at  an  abdominal  operation  which  he  had 
to  undergo. 


SPECIAL  PATHOLOGY  209 

Chapter  LXXXIV. 
QUERULOUS  INSANITY,  MORBID  LITIGIOUSNESS. 

Querulous  insanity  is  based  on  a  defect  in  the  feel- 
ing of  right  and  wrong.  Some  people  are  of  a  conten- 
tious disposition.  They  seldom  admit  being  in  the  wrong 
even  when  they  know  that  they  are  mistaken.  But  the 
disputatiousness  of  a  sane  person  has  its  limits.  He  is 
sensible  of  his  errors  and  confesses  them  to  himelf 
although  he  does  not  do  so  to  others.  The  querulous 
idiot,  however,  does  not  feel  his  errors.  Even  after  they 
have  been  clearly  and  incontestably  demonstrated  to  him, 
he  thinks  in  his  own  heart  and  soul  that  he  is  right. 

The  querulous  idiot,  about  to  commence  a  legal  ac- 
tion, cannot  conceive  of  the  possibility  that  the  court  is 
apt  to  decide  in  his  disfavor.  The  consideration  never 
enters  his  mind  that  essential  right  cannot  be  upheld  un- 
less formal  right  is  carefully  observed.  An  honest  person, 
for  instance,  may  suffer  punishment  by  court  through 
malicious  people  who  perjure  themselves.  The  judge 
has  to  inflict  a  penalty  on  the  defendant  in  such  a  case. 
A  rational  person  would  excuse  the  court,  realizing  that 
the  judge  is  not  omniscient,  that  he  has  to  act  according 
to  certain  formal  principles.  He  would  consider  the 
decree  of  penalty  as  correct  in  the  common  order  of 
things,  as  a  misfortune  for  him  in  which  he  has  to  ac- 
quiesce. The  querulous  idiot  is  unable  to  reason  this 
way.  According  to  his  feeling  the  administrator  of  jus- 
tice has  to  exculpate  him  notwithstanding  all  evidence  to 
the  contrary.  When  he  is  adjudged  guilty,  he  considers 
himself  ignobly  treated  by  the  judge  and  is  reluctant  to 
abide  by  his  judgment.    He  cannot  persuade  himself  that 


2IO  PSYCHE 

society  must  have  an  institution  to  decide  controversies, 
and  that  its  decisions  must  be  obeyed. 

The  outbreak  of  querulous  insanity  depends  on  an 
accident,  on  an  insignificant  trifle.  The  patient,  for  in- 
stance, walks  over  a  place  where  thoroughfare  is  pro- 
hibited. A  small  fine  is  imposed  on  him  for  the  tresspass. 
In  this  he  does  not  acquiesce  and  makes  all  kinds  of 
efforts  to  prove  that  the  prohibition  was  unjust.  When 
the  court  decides  again  in  his  disfavor,  he  declares  that 
the  judge  has  been  bribed.  Now  he  is  sentenced  to  a 
penalty  for  defaming  the  judge.  Again  he  does  not 
submit  to  the  verdict  and  appeals.  In  this  way  after  his 
first  collision  with  the  courts  he  cannot  extricate  himself 
from  lawsuits.  He  goes  from  one  court  to  the  other 
until  the  court  of  last  resort,  and  finding  nowhere  satis- 
faction, he  threatens  to  obtain  redress  by  force. 

A  forcible  criterion  for  the  morbidity  of  a  case  of 
litigiousness  lies  in  the  patient's  utter  indifference  to  the 
welfare  of  his  family.  He  is  willing  to  give  up  his  whole 
fortune,  to  endanger  the  subsistence  of  those  dependent 
upon  him  in  order  to  get  his  pretended  right.  Another 
criterion  of  morbidity  is  the  extreme  irritability  which 
the  litigious  imbecile  displays  whenever  the  conversation 
turns  upon  his  lawsuits.  He  cannot  bear  any  contradic- 
tion whatsoever,  and  the  slightest  difference  of  opinion 
drives  him  out  of  his  wits.  Finally  querulous  insanity 
may  be  inferred  from  a  symptom  which  extends  over 
many  years.  In  the  course  of  time  the  intellectual  pow- 
ers of  the  querulous  imbecile  decrease,  so  that  he  passes 
into  a  state  of  feeble-mindedness.  This  is  an  important 
point  for  the  distinction  of  a  sane  litigious  person  from 
a  querulous  idiot.     Besides,  the  former  would  abandon 


SPECIAL  PATHOLOGY  211 

his  lawsuits  when  he  sees  that  he  puts  all  his  fortune  at 
stake. 

The  querulous  idiot  finally  lands  in  the  insane 
asylum.  In  the  beginning  he  is  not  one  of  the  most 
agreeable  patients.  But  after  some  time  he  ceases  to 
insist  upon  his  pretended  rights  when  he  sees  that  other- 
wise he  would  not  be  dismissed  from  the  asylum. 


Chapter  LXXXV. 
ORIGINARY  INSANITY. 

Originary  insanity  resembles  primary  insanity  (Ch. 
75,  p.  176).  Like  the  paranoiacs  the  originary  idiots 
also  compose  romances  in  which  they  themselves  play  the 
principal  part.  But  originary  insanity  is  founded  upon 
congenital  mental  defects  and  appears  already  in  child- 
hood. 

The  originary  idiots  are  unable  to  discriminate  be- 
tween what  they  are  merely  thinking  of,  i.  e.,  their  mem- 
ory images,  and  that  which  their  surroundings  present 
to  their  senses,  i.  e.,  their  actual  perceptions.  To  a  slight 
degree  this  quality  is  met  with  also  in  normal  people. 
Even  a  sane  person  does  not  always  apprehend  things 
objectively,  but  frequently  there  is  a  subjective  tinge  in 
his  observations.  Children  dream  in  an  awake  state. 
Without  hallucinating  they  would  point  at  objects,  not 
present,  which  they  are  merely  thinking  of.  The  normal 
person,  therefore,  not  only  views  the  external  world  sub- 
jectively, but  even  passes  through  a  period  in  which  he 
mistakes  his  memory  images  for  objective  phenomena. 
The  originary  idiots  do  not  get  out  of  this  period  at  all. 


212  PSYCHE 

They  build  castles  in  the  air  and  believe  in  their  existence. 
In  all  sincerity  they  relate  that  they  have  participated  in 
great  events  which  have  never  taken  place.  The  position 
they  fancy  to  be  in  is  in  striking  contrast  v^^ith  reality. 

Patients  affected  v^^ith  originary  insanity  may  be 
very  intelligent  in  other  respects.  But  they  are  unsuc- 
cessful in  life  and  shun  society,  and  in  their  isolation  they 
would  manifest  other  symptoms  of  morbid  mentality. 
There  is  a  hereditary  taint  of  insanity  in  their  family, 
and  some  patients  are  descended  directly  from  insane 
parents. 


Chapter  LXXXVI. 

CONTRARY  SEXUAL  FEELING,  SEXUAL  PER- 
YERSITY. 

The  most  common  manifestation  of  sexual  per- 
versity consists  in  -antipathy  against  the  opposite,  and 
inclination  to  the  same  sex.  Individuals  showing  this 
anomaly  are  affected  with  a  defect  in  the  sexual  sphere, 
with  contrary  sexual  feeling.  But  a  difference  is  to  be 
made  between  those  afflicted  with  sexual  perversity  as 
a  disease  and  those  who  indulge  in  all  kinds  of  sexual 
aberrations  in  consequence  of  surfeit  in  Venere  and  in 
allegiance  to  the  principle  "variatio  delectat."  Patients 
with  contrary  sexual  feeling  do  not  marry.  When,  un- 
mindful of  their  abnormal  condition,  they  do  contract  a 
marriage,  they  are  unable  to  fulfill  their  marital  duties. 

Contrary  sexual  feeling  occurs  also  in  women. 

Pederasty  is  prohibited  in  many  States.  Patients 
suffering  from  sexual  perversity,  therefore,  frequently 
come  into  conflict  with  the  Penal  Code.     Non-freedom 


SPECIAL  PATHOLOGY  213 

of  the  will  is  usually  not  recognized  as  a  defense  for 
pederastic  aberrations,  so  that  patients  found  guilty  of 
such  misdeeds  have  to  undergo  the  full  penalty  of  the 
law  in  the  same  way  as  persons  with  normal  sexual  feel- 
ing convicted  of  pederasty. 

Although  treatment  of  contrary  sexual  feeling  does 
hardly  come  into  consideration,  the  patients  may  be  given 
some  useful  advice.  They  may  derive  some  benefit  from 
an  emphatic  representation  of  the  dangers  of  infection, 
theft,  and  robbery  with  which  they  are  threatened  by 
indulgence  in  their  vice  as  much  as,  or  even  more  than, 
men  seeking  the  company  of  female  prostitutes.  They 
may  heed  the  warning  when  they  are  shown  how  their 
devotion  to  male  prostitutes  is  apt  to  expose  them  to  the 
vilest  sort  of  blackmail.  For  pederasty  being  treated  as 
a  serious  crime,  the  male  prostitutes  make  use  of  this 
penal  statute  to  practice  ruthless  extortion  upon  their 
unfortunate  victims. 

If  the  patient  would  not  listen  to  the  warnings  of 
his  physician,  the  only  advice  he  can  give  him  is  to  settle 
in  a  State  in  which  pederasty  is  not  considered  a  punish- 
able offense. 

In  some  States  in  which  pederasty  is  prohibited  the 
Penal  Code  does  not  provide  punishment  for  inchastity 
between  men  when  no  imitatio  coitus  has  taken  place. 
The  penalty  is  more  rigorous  in  those  cases  in  which 
pederasty  has  been  practiced  on  individuals  under  a  cer- 
tain age.  It  is  further  very  severe  when  the  defendant 
has  satisfied  his  unnatural  desire  with  an  individual  to 
whom  he  stands  in  an  educational  relation,  being  his 
guardian  or  his  teacher,  etc. 

In  forensic  proceedings  dealing  with  sexual  per- 
versity it  is  important  to  demonstrate  that  the  defendants 


214  PSYCHE 

are  suffering  from  defective  sexual  feeling,  as  in  this  case 
the  court  would  grant  clemency.  It  is,  therefore,  useful 
to  know  that  men  affected  with  contrary  sexual  feeling 
address  their  male  paramours  by  female  pet  names  in 
speech  as  well  as  in  writing.  For  the  public  prosecutor 
may  try  to  refute  the  defendant's  plea  of  contrary  sexual 
feeling  on  the  ground  that  his  letters  containing  female 
names  prove  that  he  has  kept  up  amatory  relations  with 
women. 

The  following  case  is  interesting.  A  man  affected 
with  contrary  sexual  feeling  married  a  woman  and  even 
begot  children  with  her.  Later  he  had  to  appear  in  court 
to  answer  for  pederasty.  The  prosecuting  attorney  ob- 
jected to  the  plea  of  contrary  sexual  feeling,  adducing 
the  fact  that  the  defendant  had  even  been  able  to  beget 
children.  Thereupon  the  defendant  alleged  that  he 
had  married  a  woman  whose  appearance  was  strongly 
masculine,  and  that  he  had  succeeded  to  practice  cohabi- 
tation by  intensely  thinking  of  a  male  paramour  during 
the  act.  The  court  accepted  the  defense  and  granted 
clemency. 


Chapter  LXXXVII. 
CRETINISM. 

Cretinism  has  been  defined  as  endemic  idiocy.  But 
idiocy  occurs  endemically,  and  yet  the  patients  cannot 
justly  be  called  cretins.  Virchow  amplified,  therefore, 
the  above  definition  by  designating  cretinism  as  endemic 
idiocy  based  on  territorial  factors,  i.  e.,  on  conditions  of 
the  soil  prevailing  in  a  certain  region.  There  are  many 
causes  for  idiocy  other  than  those  which  directly  depend 


SPECIAL  PATHOLOGY  215 

upon  the  territory  in  which  the  idiotic  children  are  born 
and  reared.  Some  children  become  idiots  owing  to  their 
descent  from  debauched,  insane,  or  alcoholic  parents,  or 
owing  to  injuries  received  at  birth,  to  insufficient  nutri- 
tion in  infancy,  to  severe  infectious  diseases.  These  etio- 
logical factors  have  little  to  do  with  the  soil  of  the  terri- 
tory. They  may  be  comprised  under  the  term  social, 
because  they  depend  largely  upon  the  character  and  habits 
of  the  parents  or  the  customs  of  the  population.  But  it 
has  been  observed  that  families  in  which  these  causes 
could  not  be  established,  and  in  which  healthy  children 
had  been  born,  brought  idiotic  children  into  the  world 
after  they  had  transferred  their  domicile  into  certain 
regions,  and  having  removed  from  these  regions,  pro- 
duced anew  healthy  children.  The  idiocy  must,  therefore, 
have  had  a  territorial  cause.  Localities  in  which  cretinism 
is  endemic  are  met  with  in  Switzerland,  in  the  Pyrenees, 
in  the  Spessart  mountains,  etc. 

In  former  times  the  cretins  were  regarded  as  satanic 
prodigies,  coming  from  the  union  of  the  devil  with  a 
human  female.  The  superstition  also  prevailed  that  the 
devil  would  change  healthy  children,  leaving  monsters  in 
the  cribs  after  stealing  the  children — ''changeling," 
"Wechselbalg."  Nowadays  we  have  to  look  for  a  natural 
explanation.  Since  cretins  are  very  frequently  affected 
with  goitre,  i.  e.,  enlargement  and  degeneration  of  the 
thyroid  gland,  the  assumption  of  a  causative  relation  be- 
tween defectiveness  of  this  organ  and  cretinism  is  not 
unjustified.  This  assumption  is  corroborated  by  the  ob- 
servation that  patients  who  have  lost  the  thyroid  gland 
through  an  operation  pass  into  a  state  resembling  cretin- 
ism. It  appears,  therefore,  plausible  that  pathological 
alteration  of   the  thyroid   gland  would  have  the   same 


21.6  PSYCHE 

effect  as  its  extirpation  through  an  operation.  Kocher 
arrived  at  this  conclusion  and  considered  cretinism  a 
cachexia  strumipriva  existing  since  early  childhood. 

There  is  no  more  hideous  and  horrible  aspect  of  a 
human  being  than  the  one  presented  by  the  cretin.  The 
skull  is  deformed,  asymmetrical,  the  root  of  the  nose  is 
deeply  constricted,  the  upper  jaw  protrudes  considerably 
— prognathism  (p.  1 1 1 ) — the  skin,  consisting  of  an  excess 
of  fatty  and  oedematous  tissue,  exhibits,  especially  on 
the  face,  a  peculiar  offensive  appearance — myxoedema. 
The  unsightliness  of  the  cretin  is  still  more  enhanced  by 
a  large  goitre.  The  general  growth  of  the  body  is  re- 
duced— nanism,  dwarfishness.  The  genital  organs  show 
faulty  development.  Besides  these  somatic  anomalies, 
cretinism  is  characterized  by  dementia  of  a  high  degree. 
In  the  worst  cases  the  dementia  is  so  great  that  the  pa- 
tients are  unable  to  keep  themselves  clean,  to  take  food, 
to  learn  to  speak  a  word,  etc. 

The  answer  to  the  question  how  the  deformities  of 
the  skull  and  the  constriction  of  the  nasal  root  are 
brought  about,  may  help  to  explain  the  immediate  cause 
of  cretinism.  Virchow  teaches  that  in  cretins  the  base  of 
the  skull  is  too  short,  having  undergone  premature  arrest 
of  development,  while  the  rest  of  the  skull  has  continued 
to  grow.  The  constriction  of  the  nasal  root  is  the  result 
of  the  shortening  of  the  base  of  the  skull.  The  growth 
of  the  skull  takes  place  chiefly  at  the  synchondroses  in- 
tersphenoidalis  and  sphenooccipitalis.  The  shortening  of 
the  cranial  base  is  due,  according  to  Virchow,  to  prema- 
ture synostosis  of  these  two  synchondroses.  And,  indeed, 
he  succeeded  to  demonstrate  an  ossification  of  these  places 
in  the  skull  of  new-born  cretins.  This  finding  establishes 
his  theory  incontestably.     The  cause  of  this  premature 


SPFXIAL  PATHOLOGY  217 

ossification  probably  lies  in  a  pathological  alteration  of 
the  thyroid  gland,  produced  by  unknown  territorial  fac- 
tors. The  faulty  growth  of  the  skull  leads  to  develop- 
mental disturbances  of  the  brain  which  cause  cretinism. 

To  cure  the  surgical  cachexia  strumipriva  the  at- 
tempt has  been  made  to  introduce  into  the  system  the 
active  principle  of  the  thyroid  gland  of  which  the  system 
had  been  deprived  by  the  extirpation  of  the  gland.  The 
patients  were  fed  with  the  thyroid  gland  of  the  sheep,  and 
this  with  some  good  result.  It  is,  therefore,  advisable  to 
try  such  therapeutic  measures  also  in  cretinism. 

The  best  way  for  the  State  to  prevent  cretinism  is 
to  urge  and  help  the  inhabitants  of  the  regions  in  which 
the  disease  is  endemic  to  settle  in  other  localities. 


SECTION  III. 
DIATHESES   OF  INSANITY 


Chapter  LXXXVIII. 

HEREDITARY     PREDISPOSITION     TO     INSANITY, 
HEREDITARY  INSANITY. 

Hereditary  predisposition  to  insanity  consists  in 
diminished  power  of  resistance  of  the  whole  organism, 
and  especially  of  the  central  nervous  system.  Individuals 
affected  with  hereditary  predisposition  to  insanity  are 
liable  to  contract  psychoses  even  in  consequence  of  phy- 
siological processes.  When  the  hereditary  predisposition 
is  intense,  feeble-mindedness  may  appear  already  in  in- 
fancy. When  it  is  of  a  slighter  degree,  the  sanity  may 
not  suffer  any  harm  until  puberty.  With  the  oncoming 
of  puberty  certain  physiological  processes  take  place  in 
the  system  causing  a  state  of  unrest  and  disturbed  mental 
equilibrium.  Systemic  alterations  which  have  no  injuri- 
ous effects  on  persons  free  from  hereditary  taint  beyond 
causing  a  transitory  state  of  uneasiness  and  increased 
excitability,  call  forth  psychoses  in  those  affected  with 
hereditary  predisposition.  The  systemic  disturbances  of 
puberty  affect  adolescents  having  no  hereditary  predispo- 
sition to  insanity  only  in  a  slight  measure,  but  may  pro- 
duce psychoses  in  individuals  whose  power  of  resistance 
is  reduced  through  heredity.  If  they  are  fortunate 
enough  to  pass  this  precarious  period  without  harm  to 
their  mental  health,  disorders  of  the  mind  may  appear  in 


SPECIAL  PATHOLOGY  219 

consequence  of  other  physiological  perturbations  occur- 
ring at  a  later  age.  Thus  women  with  hereditary  predis- 
position to  insanity  may  become  mentally  ill  during  preg- 
nancy, and  more  so  during  puerperium  and  lactation. 

Hereditary  insanity,  therefore,  has  this  characteris- 
tic feature  that  it  may  be  brought  about  even  by  physio- 
logical processes.  It  is  further  marked  by  a  favorable 
prognosis  of  the  first  attack.  The  first  psychosis  on  a 
hereditary  basis  is  of  short  duration,  and  complete  recov- 
ery usually  ensues.  But  since  the  nervous  system  of  one 
who  has  gone  through  a  phychosis  is  anything  but 
strengthened  or  rendered  immune  against  mental  disease, 
patients  with  hereditary  predisposition  to  insanity  are 
subject  to  repeated  psychopathic  attacks.  A  third  char- 
acteristic of  hereditary  insanity,  therefore,  consists  in  fre- 
quent relapses.  Recurring  hereditary  insanity  shows  the 
periodic  or  the  circular  character  (p.  126).  In  the  first 
case  the  same  clinical  picture  of  mental  disease  is  repeated 
after  a  period  of  well-being,  in  the  second  case  different 
clinical  pictures  alternate.  The  prognosis  of  recurrent 
hereditary  insanity  is  very  unfavorable.  The  patients 
finally  pass  into  a  state  of  permanent  feeble-mindedness, 
of  dementia  (Ch.  78,  p.  189). 


Chapter  LXXXIX. 
HYSTERICAL  INSANITY. 

A  frequent  foundation  for  insanity  is  supplied  by  the 
neuroses,  among  which  hysteria  takes  a  prominent  place. 

The  mental  constitution  of  hysterical  individuals 
differs  distinctly  from  that  of  normal  persons,  yet  they 
are  not  to  be  regarded  as  insane.    But  in  many  instances 


220  PSYCHE 

the  hysteria  is  of  such  intensity  that  the  patients  are  fit 
subjects  for  the  insane  asylum. 

The  chief  characteristics  of  hysteria  consist  in  ex- 
traordinary irritabiHty  and  in  frequent  and  sudden  fluc- 
tuations of  the  emotions.  The  hysterical  patients  confirm 
the  poet's  words:  "Himmelhoch  jauchzend,  zum  Tode 
betriibt."  From  the  greatest  cheerfulness  they  may 
quickly  pass  into  such  despondency  as  to  harbor  ideas  of 
suicide.  Another  trait  of  the  hysterical  character  is  ex- 
treme egotism.  Hysterical  patients  are  inconsiderate  of 
others.  Behind  the  mask  of  charity,  self-sacrifice,  and  all 
the  other  virtues  they  practice  is  hidden  excessive  love  of 
self.  They  are  charitable  to  be  attractive,  self-sacrificing 
to  be  interesting,  and  perform  all  kinds  of  extraordinary 
acts  to  excite  the  attention  of  relatives  and  neighbors. 
Some  hysterical  patients  refuse  food,  or  open  their  ar- 
teries by  biting,  or  do  not  leave  their  bed  for  months,  etc., 
in  order  to  awaken  interest  and  sympathy. 

The  great  sensitiveness  of  hysterical  patients  may 
become  the  source  of  hallucinations.  When  the  latter 
supervene,  the  picture  of  a  pronounced  psychosis  is  com- 
pleted. Hysterical  insanity,  in  a  way,  represents  the 
intensification  of  the  characteristics  of  hysteria. 

The  clinical  pictures  of  hysterical  insanity  are  mani- 
fold. Some  patients  are  laboring  under  raving  agitation, 
the  sexual  factor  playing  a  prominent  part.  Women  suf- 
fering from  hysterical  insanity  display  great  irritability 
and  repugnance  towards  individuals  of  their  own  sex,  but 
are  friendly  and  even  obtrusive  towards  men.  The 
vehement  excitement  of  the  insane  hysterical  patient  dis- 
appears very  rapidly.  To-day  she  is  in  the  greatest  rest- 
lessness, tears  her  clothes,  dishevels  her  hair,  soils  her 
face ;  to-morrow  she  is  in  her  gala-costume. 


SPECIAL  PATHOLOGY  221 

Hysterical  insanity  may  appear  in  the  form  of  para- 
noia with  hallucinations  and  delusions  of  grievance  and 
furtherance. 

Melancholic  excitement,  or  better,  raptus  melancho- 
licus,  is  not  infrequent  in  hysterical  insanity.  There  may 
be  an  external  cause  for  the  melancholic  depression,  but 
it  is  out  of  proportion  to,  and  entirely  insufficient  to  ex- 
plain, the  intensity  of  the  depression.  The  melancholic 
fit  passes  away  in  a  few  days.  For  it  is  peculiar  of  hys- 
terical insanity  that  the  emotional  attitude  changes  very 
rapidly. 

Hysterical  insanity  sometimes  presents  the  picture 
of  delirium  appearing  in  spells  during  which  conscious- 
ness is  more  or  less  disturbed. 

The  prognosis  of  hysterical  insanity  is  favorable  as 
to  recovery  from  an  individual  attack,  but  unfavorable 
regarding  the  recurrence  of  mental  disorder.  An  attack 
that  has  been  preceded  by  many  others  may  result  in  per- 
manent dementia. 

Patients  suffering  from  hysterical  insanity  may 
come  into  conflict  with  the  Penal  Code  and  are  liable  to 
be  held  responsible  for  their  wrong  actions,  the  more  so 
as  they  create  the  impression  of  being  sane  and  even  in- 
telligent. Female  patients  become  implicated  in  affairs 
of  blackmail  having  a  sexual  background.  A  hysterical 
patient,  for  instance,  calls  on  a  man  in  high  position,  and 
having  been  admitted  to  his  presence  all  alone  she  accuses 
him  of  improper  conduct  towards  her.  A  prominent 
psychiatrist  relates  a  case  in  which  a  rich  hysterical 
woman  had  sacrificed  her  whole  fortune  for  a  church, 
and  then  committed  embezzlement  to  be  able  to  continue 
playing  the  interesting  role  of  patron  of  a  divine  institu- 
tion. 


222  PSYCHE 

Chapter  XC. 
PHRENASTHENIA,  PSYCHASTHENIA. 

Neurasthenia  is  another  neurosis  on  which  mental 
disorders  are  frequently  based.  The  patients  lack  psychi- 
cal stability,  so  that  unusual  strain  and  untoward  circum- 
stances and  events  easily  upset  their  mental  equilibrium. 
The  patients  not  being  insane  in  the  true  sense  of  the 
word,  their  morbid  mental  condition  might  more  appro- 
priately be  designated  as  phrenasthenia,  psychasthenia, 
than  as  insanity. 

The  predisposing  cause  of  phrenasthenia  lies  in  an 
inherited  neuropathy  or  weakness  of  the  nervous  system. 
The  exciting  cause  is  furnished  by  infectious  diseases, 
shock,  mental  and  physical  overexertion,  alcoholic  ex- 
cesses, etc. 

The  symptoms  of  phrenasthenia  are  founded  on  a 
defect  of  inhibition  which  renders  the  patients  unable  to 
control  their  ideas,  emotions,  and  impulses.  The  main 
symptoms  are  aboulia  (p.  yy),  compulsory  ideas,  phobias, 
doubts  (Ch.  35,  p.  68),  imperative  impulses  (Ch.  42, 
p.  86).  One  of  these  symptom  groups  may  predom- 
inate and  thus  impart  its  peculiar  character  to  the  clinical 
picture.  In  this  way  phobic,  doubting,  impulsive  phren- 
asthenia may  be  distinguished.  Sometimes  phrenasthenia 
resembles  paranoia  with  delusions  of  grievance,  in  other 
instances  depression  and  anxiety  prevail  so  that  the  pa- 
tients appear  to  be  suffering  from  melancholia.  In  long 
standing  cases  the  compulsory  ideas  may  give  rise  to 
hallucinations.  Phrenasthenia  ma}^  have  the  hypochon- 
driacal character,  the  patients  believing  to  be  affected 
with  all  kinds  of  physical  ailments,  such  as  a  defect  of 


SPECIAL  PATHOLOGY  223 

the  heart,  ulcer  of  the  stomach,  tumor  of  the  Hver,  soften- 
ing of  the  brain,  etc. 

The  phrenasthenic  patient  is  well  aware  that  his 
mental  condition  is  morbid.  This  insight  into  the  disease 
(pp.  128,  129),  which  contributes  to  the  distinction  of 
phrenasthenia  from  true  insanity,  adds  to  the  suffering  of 
the  patient.  It  keeps  him  in  constant  fear  of  becoming  a 
victim  of  lunacy.  To  avert  this  fate  he  looks  everywhere 
for  help.  He  consults  one  physician  after  another,  and 
is  dissatisfied  with,  and  denounces  all  of  them  when  they 
fail  to  relieve  him  from  his  worries,  fears,  compulsory 
ideas,  hallucinations,  etc. 

Somatically  the  patients  decline  a  good  deal.  They 
lose  weight  and  emaciate,  owing  to  impairment  of  sleep, 
appetite,  and  digestion. 

The  prognosis  of  phrenasthenia  is  favorable.  Even 
when  an  attack  has  lasted  one  or  two  years,  complete 
recovery  takes  place.  But  since  the  neuropathic  disposi- 
tion subsists  after  the  first  attack,  at  least  in  the  same  in- 
tensity as  before,  the  patients  are  subject  to  repeated  at- 
tacks of  mental  disorder.  Phrenasthenia  as  such  does 
not  lead  to  dementia.  But  true  insanity  may  develop  on 
the  neurasthenic  basic,  and  then  it  depends  upon  the 
severity  of  the  case  whether  or  not  permanent  feeble- 
mindedness results  from  the  psychosis. 

The  treatment  of  phrenasthenia  consists  chiefly  in 
physical  and  mental  rest  which  is  best  procured  by  re- 
moving the  patient  from  his  accustomed  surroundings 
and  placing  him  into  a  proper  sanitarium.  Nutritious 
food  and  tonics  are  helpful, 


224  PSYCHE 

Chapter  XCI. 
DEMENTIA   PRAECOX. 

While  the  mental  diseases  treated  in  the  preceding 
chapters  seldom  lead  to  intellectual  enfeeblement,  to  de- 
mentia, there  are  several  forms  of  constitutional  psy- 
choses, occurring  chiefly  at  the  ages  of  puberty  and 
adolescence,  which  are  characterized  by  a  progressive  in- 
tellectual deterioration  resulting  in  permanent  dementia. 
Indications  of  this  impairment  of  intelligence  being 
noticeable  as  early  as  the  initial  stage,  these  psychoses, 
though  differing  considerably  in  their  clinical  pictures, 
have  been  comprised  under  the  general  term  dementia 
praecox.  The  histological  examination  of  the  cerebral 
cortex  in  these  psychoses  reveals  a  definite  pathological 
process  involving  the  microscopical  cortical  elements.  In 
other  constitutional  psychoses,  however,  the  pathologic- 
anatomic  finding  is  negative. 

The  most  important  etiological  factor  of  dementia 
praecox  consists  in  a  hereditary  taint.  It  can  be  demon- 
strated in  the  majority  of  the  cases,  according  to  some 
authors  in  75  per  cent.  The  exciting  causes  are  the  same 
as  in  other  forms  of  insanity,  namely  infectious  diseases, 
physical  and  mental  overexertion,  fright,  shock,  excesses, 
and  physiological  perturbations  of  the  system.  Autoin- 
toxication has  also  been  adduced  as  a  causative  factor. 

Symptoms.  If»v  childhood  the  patients  frequently 
exhibit  various  eccentricities.  About  the  time  of  puberty 
pronounced  psychopathological  features  make  their  ap- 
pearance. 

A  characteristic  early  symptom  of  dementia  praecox 
is  the  impairment  of  the  affective  sphere,   commencing 


SPECIAL  PATHOLOGY  225 

with  the  disappearance  of  the  finer  affective  tones.  The 
patient  becomes  Hstless,  neglectful  of  his  own  person  and 
indifferent  to  friends  and  relatives,  and  loses  all  ambition. 
His  countenance  often  bears  a  dull  expression  which  is  at 
times  changed  into  a  silly  smile  that  soon  disappears.  In 
the  later  stages  the  affective  sphere  is  entirely  desolated 
(Ch.  17,  p.  36).  The  usual  affective  state  of  indifference 
and  apathy  is  sometimes  interrupted  by  periods  of  irri- 
tability during  which  impulsive  outbreaks  occur. 

The  ideational  sphere  is  frequently  marked  by  delu- 
sions. They  usually  bear  the  stamp  of  absurdity  (p.  55) 
and  are  strengthened  by  hallucinations,  especially  of  hear- 
ing. The  association  of  ideas  is  inordinate.  In  conver- 
sation the  patient  would  jump  from  one  thing  to  another 
entirely  disconnected.  The  whole  ideational  process  is 
characterized  by  desultoriness.  The  natural  congruity 
between  the  ideational  contents  and  the  affective  state  is 
wanting.  The  patient,  for  instance,  would  manifest 
cheerfulness  while  affirming  to  be  depressed  or  he  would 
wxep  at  a  joyous  idea  arising  in  his  consciousness — para- 
mimia (Ch.  39,  p.  81). 

The  power  of  memory  diminishes  gradually.  For 
remote  events  it  remains  fairly  well  preserved  for  a  long 
time.  Deficiency  of  memory  concerning  recent  occur- 
rences is  noticeable  already  at  an  early  stage.  Sometimes 
•the  failure  of  memory  is  surprising.  The  patient  would 
state  correctly  his  age,  year  and  date  of  his  birth,  but 
would  be  unable  to  recall  his  name. 

Disturbances  of  the  volitional  activity  form  a  prom- 
inent feature  of  dementia  praecox.  Various  inordinate 
and  purposeless  movements  indicate  the  deterioration  of 
the  will  power.  Tics,  i.  e.,  queer,  abrupt  movements  of 
muscles  or  muscle  groups,  especially  of  face,  neck,  and 


226  PSYCHE 

upper  limbs,  are  frequently  observed  in  the  precocious 
dements  (Ch.  38,  p.  79).  Often  the  patients  exhibit 
stereotypy,  verbigeration,  mannerism.  They  remain  in 
one  posture  or  repeat  the  same  movement  for  any  length 
of  time.  They  eat,  speak,  and  walk  in  a  peculiar  affected 
manner.  They  use  high-sounding,  outlandish  words  and 
reiterate  the  same  phrase  many  times.  Sometimes  they 
speak  and  write  in  doggerels,  the  style  of  which  is  foolish 
and  bombastic.  In  advanced  stages  the  patients  jabber 
for  hours  and  days,  repeating  senseless  words  and  syl- 
lables over  and  over  again. 

The  abnormal  motor  phenomena  mentioned  above 
are  frequently  associated  with  negativism,  i.  e.,  non- 
sensical resistance  to  every  influence  (Ch.  40,  p.  82). 
The  patient  recedes  when  a  friend  approaches  him.  He 
hides  in  a  corner,  in  a  closet,  or  under  the  bed  when  the 
physician  calls  on  him.  He  declines  to  fulfill  the  most 
reasonable  request,  and  even  does  just  the  opposite  of 
what  he  is  asked  to  do.  When  requested  to  show  his 
tongue,  he  presses  his  teeth  together.  He  even  does  not 
comply  with  his  physical  needs,  refusing  to  take  nour- 
ishment, to  void  urine,  or  to  evacuate  his  bowels. 

Hypersuggestibility  is  another  defect  of  volition  met 
with  in  dementia  praecox,  sometimes  together  with  neg- 
ativism (Ch.  40,  p.  82).  The  patient  responds  too  read- 
ily to  incidental  influences.  The  slightest  stimulus  may 
call  forth  a  reaction,  many  movements  thus  appearing  to 
ensue  automatically.  Imitation  of  actions  seen,  echo- 
praxia,  and  repetition  of  words  and  phrases  heard,  echo- 
lalia,  result  from  this  impairment  of  the  will  power. 

The  psychomotor  response  of  the  precocious  dement 
is  slow.  When  a  question  is  put  to  him,  a  few  seconds 
may  elapse  before  he  makes  an  attempt  to  answer  it. 


SPECIAL  PATHOLOGY  227 

Sometimes  the  precocious  dement  is  unable  to  answer 
in  a  direct  manner  the  simplest  questions.  He  begins  to 
reply,  but  incidental  ideas  deflect  his  train  of  thought, 
rendering  the  answer  entirely  irrelevant — paralogia, 
"Vorbeireden"  (p.  83). 

Finally,  volitional  disturbance  is  manifested  by  lack 
of  self-control.  The  occasional  emotional  outbursts  lead 
to  violent  acts.  In  a  fit  of  rage  the  patient  may  tear  his 
clothes,  break  furniture,  assault  anybody  crossing  his 
way,  etc. 

The  power  of  understanding  shows  a  progressive 
deterioration.  This  characteristic  symptom  of  dementia 
praecox  is  noticeable  from  the  inception  of  the  disease. 
As  the  latter  advances  the  .patient  becomes  more  and 
more  stupid,  his  speech  nonsensical,  incoherrent.  In  the 
last  stages  his  utterances  form  a  foolish  medley  of  words, 
a  word-salad  ("Wortsalat").  Deficiency  of  the  power  of 
understanding  constitutes  a  prominent  feature  of  demen- 
tia praecox  in  all  its  stages. 

Consciousness  is  usually  clear  and  orientation  is, 
as  a  rule,  little  disturbed.  In  spells  of  great  excite- 
ment the  consciousness  is  somewhat  clouded.  Stuporous 
conditions  (Ch.  ']2,  p.  159)  are  frequent  in  dementia 
praecox.  They  are  characterized  mainly  by  disturbance 
of  consciousness  and  volition. 

Certain  physical  symptoms  frequently  met  with  in 
dementia  praecox  may  be  of  diagnostic  value.  Apoplec- 
tiform and  epileptiform  attacks  occur  in  this  disease  in 
the  same  way  as  in  paretic  insanity  (pp.  251,  255).  The 
apoplectiform  attacks  are  sometimes  followed  by  para- 
lyses. Certain  convulsive  movements  are  quite  character- 
istic of  dementia  praecox,  as  the  spasmodic  distortions 
of  the  mouth  (p.  80),  rolling  of  the  eyes,  wrinkling  of 


228  .  PSYCHE 

the  forehead,  etc.  These  motor  disturbances  may  have 
some  relation  to  the  increased  irritabihty  of  the  muscles, 
not  infrequently  observed  in  the  precocious  dements.  A 
slight  mechanical  irritation  of  a  muscle  calls  forth  a  long 
lasting  contraction  which  is  visible  as  a  tumor  over  the 
muscle,  the  so-called  idiomuscular  swelling.  Tremor  is 
often  present.  The  tendon  reflexes  are  usually  increased. 
The  pupils  are  often  dilated  and  show  great  mobility 
which  may  amount  to  a  pronounced  hippiis.  Vasomotor 
disturbances,  such  as  cyanosis,  local  oedema,  dermo- 
graphy,  are  frequently  seen.  At  times  there  is  profuse 
perspiration.  Exophthalmic  goitre  is  not  rare  in  demen- 
tia praecox. 

Dementia  praecox  appears  in  three  forms,  the  hebe- 
phrenic, catatonic,  and  paranoiic.  No  symptom  belongs 
exclusively  to  one  form.  The  division  is  based  rather 
upon  certain  symptoms  being  more  prominent  in  one  form 
than  in  the  other. 

Hebephrenic  Form.  The  hebephrenic  form  of 
dementia  praecox  has  a  prodromal  stage  of  a  few  years 
marked  by  neurasthenic  and  hypochondriacal  symptoms 
and  occasional  spontaneous  outbursts  of  temper.  The 
inception  of  pronounced  psychopathic  manifestations  is 
slow.  This  is  one  of  the  features  which  distinguish  the 
hebephrenic  from  the  catatonic  form. 

The  hebephrenic  form  has  been  divided  into  two 
groups,  dementia  simplex  and  hebephrenia  proper.  The 
difference  between  the  two  consists  chiefly  in  dementia 
simplex  running  a  more  protracted  course  and  having 
less  often  periods  of  excitement  than  hebephrenia  proper. 

Dementia  simplex  is  characterized  by  general  apathy 
and  a  slowly  progressing  intellectual  enfeeblement.  The 
latter  sometimes  reaches  but  a  moderate  degree  and  then 


SPECIAL  PATHOLOGY  229 

the  disease  is  arrested.  Precocious  dements  of  this  sort 
are  found  among  ragamuffins  and  vagabonds,  which  is 
forensically  of  great  importance.  In  the  majority  of 
cases  the  disease  progresses  until  the  patients  become 
helpless  mental  wrecks.  Impulsive  outbreaks,  delusions, 
stereotypy,  stupor,  etc.,  do  occur,  but  are  comparatively 
rare. 

In  hebephrenia  proper,  on  the  other  hand,  excitative 
states  are  more  frequent  and  of  longer  duration.  Hallu- 
cinations and  delusions  are  more  marked,  although  they 
do  not  form  as  prominent  a  feature  as  in  other  forms  of 
dementia  praecox.  In  the  early  stages  the  delusions  are 
of  a  depressive  and  persecutory  character.  The  patient 
believes  everybody  to  harbor  inimical  designs  against 
him.  Later  the  delusions  are  expansive  in  nature.  The 
impulsive  outbreaks  and  the  delusions  may  lead  to  violent 
acts.  Disturbances  of  volition,  such  as  automatism, 
stereotypy,  mannerism,  negativism,  etc.,  are  seen  quite 
often.  Hebephrenia  proper  finally  passes  into  a  stage  of 
permanent  dementia. 

Catatonic  Form.  The  catatonic  form  of  dementia 
praecox  differs  from  the  hebephrenic  form  through  a 
more  acute  onset  and  through  more  frequent  states  of 
excitement  and  stupor.  Hallucinations  and  delusions  are 
also  somewhat  more  conspicuous  in  the  catatonic  form 
than  in  hebephrenia. 

After  a  period  in  which  neurasthenic  and  hypochon- 
driacal symptoms  prevail,  the  mental  disorder  begins  sub- 
acutely  with  anxiety  and  depression  and  presents  for 
some  time  a  clinical  picture  resembling  melancholia. 
Now  and  then  the  patient  utters  delusions  of  a  perse- 
cutory character.  Owing  to  the  depression,  a  state  of 
mutism  may  persist  for  days,  weeks,  and  months.     At 


230  PSYCHE 

times  the  depression  is  interrupted  by  impulsive  outbreaks 
driving  the  patient  to  violent  acts.  Suicidal  attempts  are 
not  rare  in  this  stage.  The  depressive  stage  is  followed 
by  a  period  of  excitement  marked  by  hallucinations,  delu- 
sions, and  frequent  explosions  of  violence.  In  such  spells 
the  patient  displays  destructiveness,  aggressiveness,  and  a 
homicidal  tendency.  This  period  is  succeeded  by  a  stage 
of  catatonia  or  stupor  with  catalepsy.  Excitative  and 
stuporous  states  alternate  several  times  and  finally  the 
patient  passes  into  a  state  of  permanent  dementia. 

In  many  cases  the  sequence  of  the  stages  is  different 
from  the  one  just  outlined.  The  stage  of  depression  may 
be  followed  by  stupor  or  after  the  preliminary  neuras- 
thenic symptoms  the  mental  disease  may  set  in  with 
stupor. 

The  stupor  varies  greatly  in  duration  and  intensity. 
It  may  last  a  few  hours  or  several  months.  There  may 
be  complete  loss  of  consciousness  and  great  rigidity  of 
the  muscles,  or  the  consciousness  is  little  disturbed,  and 
there  is  only  a  general  apathy  associated  with  moderate 
muscular  tension.  In  the  stuporous  conditions  with  but 
slight  impairment  of  consciousness  disturbances  of  voli- 
tion, such  as  stereotypy,  verbigeration,  mannerism,  neg- 
ativism, automatism,  and  hypersuggestibility  are  quite 
frequent. 

Paranoiic  Form.  In  the  paranoiic  form  of  demen- 
tia praecox  delusions  form  a  predominant  feature.  They 
persist  for  years  while  in  the  other  forms  they  tend  to 
evanesce  in  a  comparatively  short  time. 

This  form  may  be  distinguished  into  two  groups. 
In  the  first  one,  dementia  paranoides  (Kraepelin),  indi- 
cations of  intellectual  enfeeblement  appear  early  and  pro- 
nounced dementia  develops  quite  rapidly.    The  delusions 


SPECIAL  PATHOLOGY  231 

in  this  group  are  changeable,  nonsensical,  incoherent, 
lacking  system.  In  the  second  group,  however,  the  delu- 
sions are  more  stable  and  coherent  and  systematized  (Ch. 
29,  p.  58)  for  several  years;  then  they  become  confused 
and  fade  away  leaving  a  moderate  dementia. 

In  the  early  stages  of  the  paranoiic  form  the  affec- 
tive state  is  that  of  depression  and  anxiety,  and  the  delu- 
sions have  a  persecutory  character.  Later  the  mood  is 
rather  joyous,  exalted,  and  the  delusions  are  of  a  cheerful 
nature.  At  times  great  irritability  prevails,  giving  rise 
to  impulsive  outbreaks. 

The  conduct  of  the  patient  is  in  conformity  with  his 
delusions.  In  the  depressive  stage  he  is  reserved, ,  cau- 
tious, suspicious.  In  the  stage  of  exaltation  he  is  rather 
loquacious  and  dresses  himself  up  in  gaudy  attire.  While 
in  a  mood  of  irritability  he  may  be  violent. 

Stupor  occurs  but  seldom  in  the  paranoiic  form. 
Stereotypy  and  negativism,  however,  are  not  rare,  and 
mannerism  in  eating,  speaking,  walking,  etc.,  is  fre- 
quently observed. 

Course  and  Prognosis  of  Dementia  Praecox. 
The  course  of  dementia  praecox,  from  the  first  appear- 
ance of  pronounced  psychopathological  symptoms  until 
the  beginning  of  the  final  stage  of  permanent  dementia, 
extends  over  several  years.  Remissions  occur  lasting  in 
some  instances  many  years.  The  progress  of  the  disease 
may  be  arrested  at  a  certain  stage.  This  is  especially  the 
case  in  the  hebephrenic  form.  Fatal  termination  is 
usually  due  to  an  intervening  disease,  such  as  tubercu- 
losis, to  which  especially  stuporous  patients  are  frequently 
subject.  Eight  per  cent,  of  hebephrenic  and  13  per  cent, 
of  catatonic  patients  get  well  to  the  extent  of  being  fit 
for  useful  occupation.     But  even  in  such  cases  a  closer 


232  PSYCHE 

examination  reveals  mental   defects.     Restitutio   ad   in- 
tegrum, if  it  occurs  at  all,  is  very  rare. 

Differential  Diagnosis  of  Dementia  Praecox. 
In  dementia  praecox  there  are  indications  of  an  impair- 
ment of  the  reasoning  power  even  at  the  onset  of  the 
psychosis.  This  point  in  connection  with  the  youthful 
age  of  the  patient  is  almost  pathognomonic.  There  is 
only  one  other  form  of  insanity  in  which  signs  of  en- 
feeblement  of  the  intellect  are  present  as  early  as  the 
initial  stage,  namely  paretic  insanity  (p.  248).  In  gen- 
eral the  diagnosis  must  be  based  on  the  entire  clinical 
picture.  In  the  early  stages  dementia  praecox  resembles 
phrenasthenia  (Ch.  90,  p.  222),  from  which  it  is  distin- 
guished by  the  emotional  apathy,  by  the  slow  psycho- 
motor response,  and  by  indications  of  intellectual  de- 
terioration, of  mannerism,  and  of  other  motor  anomalies. 
The  depression  of  dementia  praecox  differs  from  melan- 
cholia by  the  character  of  the  accompanying  delusions. 
The  characteristic  melancholic  ideas  of  sinfulness  are 
missing  in  dementia  praecox.  The  states  of  excitement 
and  restlessness  in  dementia  praecox  are  not  uniform  and 
steady,  but  moments  of  quiet  and  apathy  intervene,  while 
in  mania  the  agitation  is  constant  and  associated  with  the 
characteristic  cheerfulness.  In  dementia  praecox  the 
pupillary  reaction  is  lively  and  motor  defects  of  speech 
and  of  writing  and  other  pareses  are  missing,  in  contra- 
distinction to  paretic  insanity,  which  is  characterized  by 
such  motor  disturbances.  In  the  paranoiic  form  of  de- 
mentia praecox  there  are  early  indications  of  impairment 
of  the  intellect  and  the  delusions  are  marked  by  ab- 
surdity. In  true  paranoia,  however,  the  reasoning  power 
remains  unabated  for  a  long  time,  and  the  delusions  are 
fairly  well  accounted  for. 


SPECIAL  PATHOLOGY  233 

Therapy.  The  treatment  of  dementia  praecox  is 
chiefly  preventative.  Children  from  psychopathic  fam- 
ihes  should  not  be  overexerted  either  physically  or  men- 
tally. They  should  be  brought  up  to  observe  regularity 
of  habits  and  to  avoid  all  kinds  of  excesses.  They  should 
not  be  allowed  to  drink  alcohol  and  to  smoke  tobacco. 
Especially  masturbation  must  be  prevented.  Patients  suf- 
fering from  dementia  praecox  should  be  removed  from 
their  home  surroundings  and  put  into  a  psychopathic  hos- 
pital where  they  can  be  best  taken  care  of.  Only  very 
mild  cases  may  be  treated  at  home. 


Chapter  XCII. 

RECURRENT   INSANITY,   MANIC=DEPRESSIVE 
INSANITY. 

F.  H.  V.  Grashey  in  his  wonderfully  lucid  lectures  on 
psychiatry  never  spoke  of  manic-depressive  insanity. 
Only  occasionally  he  touched  upon  periodic  and  circular 
insanity  which  other  authors  range  with  a  large  class  of 
psychoses  designated  as  manic-depressive  insanity.  Al- 
though this  treatise  conforms  quite  exactly  with  the  teach- 
ings of  V.  Grashey,  it  seems  advisable  to  discuss  briefly 
this  class  of  mental  diseases,  as  the  views  of  those  authors 
have  received  wide  recognition. 

The  clinical  picture  of  melancholia  (p.  154)  is  com- 
posed of  three  cardinal  symptoms,  namely :  i )  depressed 
affective  state  or  sad  mood  ("traurige  Verstimmvmg," 
p.  31)  ;  2)  dearth  of  ideas  and  retardation  of  the  idea- 
tional process  (p.  41)  ;  3)  diminished  frequency  of  voli- 
tional manifestations  (p.  78).     For  the  sake  of  brevity 


234  PSYCHE 

these  three  symptoms  may  be  called  respectively:  dejec- 
tion, immobility  of  thought,  inactivity.  It  will  be  more 
conducive  to  clearness  to  avoid  in  this  discussion  the  term 
depression  for  the  reason  that  it  does  not  refer  to  mood 
alone,  but  also  to  other  mental  states  which  may  be  de- 
pressed, while  dejection  usually  implies  the  affective  state 
only. 

According  to  v.  Grashey  immobility  of  thought  and 
inactivity  are  not  independent  from  dejection,  but  con- 
ditioned by  it  so  that  wherever  the  latter  symptom  is 
present  we  will  always  meet  with  the  other  two  symptoms 
(Ch.  14,  p.  33).  A  sad  patient  is  quiet,  and  his  thoughts 
are  sluggish.  Only  when  the  dejection  becomes  increased 
to  anxiety  and  fear  the  inactivity  gives  way  to  restless- 
ness. Apparently  the  patient  then  produces  also  more 
ideas.  In  reality,  however,  it  is  one  and  the  same  appre- 
hensive idea  that  always  returns,  keeping  up  the  restless- 
ness (pp.  s^,  34). 

The  opposite  of  melancholia  is  mania,  the  clinical 
picture  of  which  is  founded  on  the  three  cardinal  symp- 
toms:  i)  exalted  affected  state  or  cheerful  mood  ('liei- 
tere  Verstimmung,"  p.  36)  ;  2)  abundance  of  ideas  and 
acceleration  of  the  ideational  process  (p.  42);  3)  in- 
creased frequency  of  volitional  manifestations  (p.  78). 
These  three  symptoms  may  be  called  respectively :  exalta- 
tion, mobility  of  thought,  activity.  The  term  "flight  of 
ideas"  (pp.  36,  42),  often  used  for  the  second  symptom, 
will  more  appropriately  be  reserved  for  the  highest  de- 
grees of  the  symptom. 

In  mania  there  is  the  same  relation  between  the  three 
cardinal  symptoms  as  in  melancholia.  They  are  not  co- 
ordinate, but  from  exaltation  necessarily  result  mobility 
of  thought  and  activity   (Ch.   16,  p.  35).      In  a  fit  of 


SPECIAL  PATHOLOGY  235 

anger,  however,  due  to  resistance  and  obstacles  (p.  163) 
or  to  hallucinations  contrary  to  the  patient's  delusions 
(p.  166),  his  cheerful  mood  may  not  be  obvious,  so  that 
there  are  apparently  mobility  of  thought  and  activity 
without  exaltation.  The  wrathful  mood  may  even  be 
mistaken  for  dejection. 

The  hypothesis  explaining  the  influence  of  the  affect- 
ive state  upon  the  ideational  process  (Ch.  8,  p.  19),  and 
at  the  same  time  the  manic  and  melancholic  syndromes, 
is  supported  by  pathological  as  well  as  normal  phenomena. 
The  association  of  dejection,  immobility  of  thought,  in- 
activity on  one  side,  and  of  exaltation,  mobility  of 
thought,  activity  on  the  other  side,  forms  the  rule  not 
only  in  patients,  but  also  in  sane  individuals.  In  a  sad 
mood  we  have  difficulty  in  thinking  and  prefer  to  be 
quiet,  our  thoughts  flow  readily,  and  we  are  lively  and 
active  in  a  cheerful  frame  of  mind. 

The  foregoing  explanation  of  mania  and  melancholia  will 
hardly  agree  with  Kraepelin's  views  on  manic-depressive  insanity. 
According  to  this  author  every  mania  and  almost  every  melancholia, 
as  defined  before,  constitute  different  phases  of  one  and  the  same 
disease,  which  is  characterized  by  repeated  attacks  of  mania,  or  of 
melancholia,  or  of  mixed  states  in  which  the  cardinal  manic  and 
melancholic  symptoms  are  combined.  From  the  three  pairs  of 
opposite  symptoms  would  result  eight  different  forms.  Starting 
from  mania,  composed  of  exaltation,  mobility  of  thought,  and 
activity,  the  other  seven  forms  are  obtained  by  replacing  one  or 
more  of  these  symptoms  by  their  opposites.  The  combination  of 
exaltation,  mobility  of  thought,  activity,  constitutes  the  manic  phase 
of  manic-depressive  insanity,  and  the  combination  of  dejection, 
immobility  of  thought,  inactivity,  forms  the  depressive  phase  of 
manic-depressive  insanity.  The  former  does  not  differ  materially 
from  mania  (p.  162),  and  the  latter  from  melancholia  (p.  154) 
as  described  before  in  this  treatise. 

Considering  only  those  cases  of  manic-depressive 
insanity  in  which  the  repeated  attacks  are  always  purely 


236  PSYCHE 

manic  or  purely  melancholic,  or  alternately  sometimes 
purely  manic,  at  other  times  purely  melancholic  in  char- 
acter, the  lengthy  names  of  the  disease  and  its  attacks 
may  be  dispensed  with.  It  has  been  known  long  ago 
that  patients  may  go  through  many  attacks  of  mania 
or  melancholia  and  that  these  clinical  pictures  may  alter- 
nate (p.  1 68).  A  patient  subject  to  attacks  of  mania  or 
melancholia,  separated  by  lucid  intervals,  suffers  from 
recurrent  mania  or  recurrent  melancholia.  When  the 
intervals  are  fairly  regular,  we  speak  of  periodic  mania 
or  melancholia.  In  circular  insanity  there  are  cycles 
composed  of  mania,  melancholia,  and  a  lucid  interval. 
When  the  intervals  of  circular  insanity  are  missing  or  too 
short  to  be  perceptible,  we  have  alternating  insanity. 
So  far  there  seems  to  be  no  need  to  abandon  the  long 
approved  terms  mania  and  melancholia  and  to  replace 
them  by  the  cumbersome  names  manic  phase  of  manic- 
depressive  insanity  for  mania,  and  depressive  phase  of 
manic-depressive  insanity  for  melancholia.  We  may 
simply  speak  of  recurrent  insanity  and  have  to  bear  in 
mind  that  an  attack  of  mania  or  melancholia,  although 
it  has  ended  in  partial  or  complete  recovery,  may  be  re- 
peated at  some  future  time  in  the  same  or  the  opposite 
character,  especially  if  the  case  gives  a  history  of  previous 
attacks. 

But  if  there  be  cogent  reasons  to  regard  some  attacks  of 
recurrent  insanity  as  truly  mixed  states,  we  must  acknowledge  the 
modern  views  on  manic-depressive  insanity  and  accept  the  names 
for  the  disease  and  its  single  attacks  as  appropriately  selected. 
The  attacks  of  recurrent  insanity  very  often  lack  the  character  of 
pure  mania  or  pure  melancholia,  but  apparently  contain  manic  and 
melancholic  symptoms  at  the  same  time.  Indeed,  many  authors 
maintain  that  pure  mania  is  of  very  rare  occurrence. 

Kraepelin  assumes  that  the  cardinal  manic  and  melancholic 


iMfU 


SPECIAL  PATHOLOGY  237 

symptoms  may  combine  in  any  manner.     He  thus   arrives   at  six 
mixed  states. 

1.  In  the  manic  symptom  complex  the  exaltation  may  be 
replaced  by  a  depressed  mood.  This  form  is  the  so-called  irascible 
mania  {"sornige  Manie").  The  patients  are  constantly  in  an  angry 
frame  of  mind  and  vent  their  wrath  by  inveighing  against  every- 
body. When  the  excitement  is  slight,  the  picture  of  nagging  mania 
{"norgelnde  Manie")  is  present,  the  patients  being  discontented  arid 
finding  fault   with   everything  and   everybody. 

2.  When  in  irascible  mania  mobility  of  thought  is  replaced 
by  its  opposite,  there  arises  the  picture  of  depressive  excitement. 
The  patients  display  great  restlessness.  They  talk  incessantly,  tor- 
menting themselves  and  others  with  the  same  hypochondriacal  ideas. 

3.  When  in  depressive  excitement  the  depressed  mood  gives 
way  to  exaltation,  there  is  produced  the  picture  of  mania  with 
dearth  of  ideas  ("gedankenarme  Manie").  This  form  is  frequently 
met  with.  The  patients  perceive  but  slowly  and  inaccurately,  do 
not  comprehend  questions  before  they  have  been  repeated  several 
times.  They  create,  therefore,  the  impression  of  being  weak-minded, 
though  later  they  may  turn  out  to  be  quite  intelligent.  The  mental 
condition  of  the  patients  is  very  fluctuating,  so  that  at  times  they 
are  adroit  and  quick  at  repartee,  while  at  other  times  they  cannot 
be  moved  to  say  a  word.  The  patients  are  in  a  cheerful  mood  and 
laugh  at  every  trifle.  Their  talk  is  incoherent,  twaddly,  empty. 
They  don't  speak  much  nor  hastily.  For  a  long  time  they  may  remain 
silent,  if  they  are  not  stimulated.  In  the  course  of  a  conversation 
they  are  at  first  unable  to  find  words,  but  later  they  may  develop 
a  torrent  of  verbiage.  The  impulse  for  movement  is  limited  to 
grimacing,  occasional  dancing  about,  plucking  at  the  hair  and  the 
clothes.  Some  patients  conduct  themselves  orderly  and  quietly,  so 
that  superficial  observation  would  not  reveal  any  excitement.  They 
are  in  an  exalted  mood,  now  and  then  somewhat  irritated,  and  at 
times  show  themselves  rude  only  to  burst  into  merry  laughter  after 
a  while.  Other  patients  sit  around  idly,  laugh  boisterously,  and 
display  a  tendency  to  mischievous  tricks,  such  as  smearing  the 
walls,  plugging  up  the  keyholes,  etc.,  while  for  useful  occupation 
they  are  entirely  unfit. 

At  times  violent  outbreaks  occur  in  these  patients,  but  they 
are  of  short  duration.    Even  genuine  mania  may  appear  transitorily. 

4.  Cheerful  mood  may  substitute  the  dejection  in  the  clinical 
picture  of  melancholia.  The  condition  then  obtained  is  the  so-called 
manic  stupor.    The  patients  are  indifferent  to  their  environment,  do 


238  PSYCHE 

not  answer  a  question,  at  best  they  mumble  with  a  low  voice  in 
reply.  They  smile  without  perceptible  cause,  lie  quietly  in  bed, 
fumble  with  the  bed  clothing,  and  decorate  themselves  phantastically, 
all  this  without  evident  emotional  excitement.  Sometimes  the 
patients  give  utterance  to  delusions  of  variable  contents.  Orienta- 
tion is  usually  little  disturbed.  Sometimes  catalepsy  is  observed. 
Occasionally  impulsive  outbreaks  occur,  the  patients  suddenly  be- 
coming very  violent  and  manifesting  a  tendency  to  dangerous  acts. 
At  other  times  they  may  be  quiet,  collected,  and  intelligent,  but 
such  a  condition  does  not  last  very  long.  Some  patients  walk  about 
the  ward  in  measured  steps  and  barely  speak  a  word,  but  utter 
now  and  then  a  witty  remark.  Frequently  the  patients  remember 
everything  that  has  occurred,  but  are  unable  to  explain  their  strange 
conduct. 

5.  In  the  clinical  picture  of  melancholia  immobility  of  thought 
may  be  replaced  by  its  opposite.  The  patients  are  quiet,  silent, 
despondent,  yet  they  exhibit  curiosity  and  interest  in  their  environ- 
ment. When  they  break  their  silence,  they  relate  that  many  ideas 
pass  through  their  minds.  They  read  and  write  a  good  deal,  com- 
posing long  stories  which  treat  of  their  fears  and  delusions  of  sin. 

6.  Finally  Kraepelin  "believes  to  have  observed  states  which 
would  correspond  to  the  presupposed  association  of  flight  of  ideas 
and  cheerful  mood  with  phychomotor  inhibition."  These  patients 
are  gay,  at  times  somewhat  irritable,  distractible,  inclined  to  jokes. 
When  spoken  to,  they  readily  start  a  long  rigmarole  with  flight  of 
ideas  and  numerous  sound  associations.  Their  general  behavior, 
however,  is  remarkably  tranquil.  They  lie  quietly  in  bed,  now  and 
then  uttering  a  remark  or  laughing.  But  an  inner  tension  seems  to 
influence  the  patients,  for  they  frequently  become  very  violent  with- 
out any  cause. 

It  is  diflicult  to  adjust  the  theory  of  the  relation  between 
ideational  process,  volitional  activity,  and  affective  state  (Ch.  8,  p.  19, 
Ch.  14,  p.  33,  Ch.  16,  p.  36)  to  these  mixed  states.  For  if  it  be  cor- 
rect that  exaltation  causes  mobility  of  thought  and  activity,  while 
dejection  produces  immobility  of  thought  and  inactivity,  truly  mixed 
states  cannot  occur.  But  perhaps  the  above  mixed  states  need  not 
be  taken  as  such.  Thus  "irascible  mania"  may  be  considered  as  pure 
mania  in  which  the  exaltation  is  hidden  by  a  wrathful  mood  (pp.  163, 
166,  235),  but  not  replaced  by  its  opposite,  viz.,  dejection.  Similarly 
"depressive  excitement"  may  be  explained  as  pure  melancholia  in 
which  the  dejection  is  increased  to  anxiety  and  fear,  an  affective  state 
that  causes  restlessness — melancholia    agitatia     (pp.    33,   34,    i55)- 


SPECIAL  PATHOLOGY  239 

In  "manic  stupor"  the  affective  state  is  that  of  indifference;  there, 
is  neither  genuine  exaltation,  nor  dejection.  An  occasional  smile 
or  witty  remark  does  not  necessarily  indicate  true  exaltation.  Possi- 
bly we  may  detect  now  and  then  a  sorrowful  expression  of  the 
countenance,  when  we  observe  the  patient  without  preconceived 
assumption.  Casual  restlessness  is  not  necessarily  manic  in  nature, 
but  may  be  due  to  fear  or  to  hallucinations. 

The  occurrence  of  the  mixed  state  composed  of  exaltation, 
mobility  of  thought,  and  inactivity  is  somewhat   doubtful  yet. 

The  two  mixed  states,  namely  mania  with  dearth  of  ideas 
{"gedankenarme  Manie")  and  the  other  one  which  in  contrast  may 
be  called  melancholia  with  abundance  of  idea  {"gedankenreiche 
'  Melancholie")  can  hardly  be  brought  in  conformity  with  the  theory 
that  exaltation  produces  mobility,  and  dejection,  immobility  of 
thought.  If  for  this  reason  the  theory  is  to  be  abandoned,  there 
remains  the  important  question  to  be  answered  why  normally  as 
well  as  pathologically  exaltation  is  so  often  associated  with  accelera- 
tion, and  dejection  with  retardation  of  the  ideational  process.  Until 
this  question  will  have  received  a  solution  with  which  the  modern 
views  on  manic-depressive  insanity  do  not  conflict,  there  is  good 
justification  in  avoiding  this  misleading  designation  of  the  disease 
and  in  abiding  by  the  old  term  recurrent  insanity,  the  more  so  as 
Kraepelin  himself,  the  foremost  exponent  of  the  theory  of  manic- 
depressive  insanity,  remarks :  "Die  Lehre  von  den  Mischzustanden 
ist  noch  zu  unfertig,  als  dass  eine  weitergehende  Kennzeichnung 
der  einzelnen   Formen  moglich  ware." 

Etiology.  Hereditary  psychopathic  predisposition 
is  so  frequently  met  with  in  recurrent  insanity  that  the 
disease  may  be  classed  with  hereditary  insanity  which,  as 
has  been  pointed  out  before,  is  characterized  by  a  strong 
tendency  to  recur  (p.  218).  A  hereditary  taint  can  be 
established  in  80  per  cent,  of  the  cases.  The  first  attack 
usually  occurs  before  the  age  of  25  years,  but  in  some 
instances  as  early  as  the  tenth,  in  others  as  late  as  the 
fiftieth  year  of  age.  Physiological  perturbations  of  the 
system  may  bring  on  the  disease.  This  is  perhaps  the 
reason  why  it  is  more  frequent  among  women  than 
among  men,   the  former  being  more  often  subject   to 


240  PSYCHE 

physiological  systemic  agitations  than  the  latter,  at  the 
appearance  of  the  first  menses,  and  during  pregnancy, 
puerperium,  lactation,  and  climacterium.  In  physiologi- 
cal disturbances  furnishing  an  exciting  cause  of  the  dis- 
ease lies  another  hereditary  feature  (p.  218).  The  usual 
exciting  causes  of  insanity,  such  as  shock,  fright,  worry, 
excesses,  infectious  diseases,  physical  and  mental  over- 
exertion, are  even  more  effective  in  recurrent  insanity. 

Course  and  Prognosis.  The  disease  begins  with  an 
attack  of  melancholia  or  mania  which  ends  in  recovery. 
The  attack  is  repeated  in  the  same  character  after  a 
longer  or  shorter  lucid  interval.  Several  uniform  at- 
tacks follow — recurrent  (periodic)  melancholia  or  mania. 
Sometimes  an  attack  unexpectedly  presents  the  opposite 
character.  Only  in  a  small  number  of  cases  the  disease 
passes  directly  from  one  phase  into  the  other — alterna- 
ting insanity — or  is  interrupted  after  two  opposite  phases 
by  a  lucid  interval — circular  insanity.  The  first  attack, 
in  the  majority  of  the  cases,  is  of  a  depressive  character, 
especially  in  women  and  in  young  patients.  The  depres- 
sion is  followed  by  a  period  of  well-being,  or  passes  unin- 
terruptedly into  a  manic  stage  which  ends  in  recovery. 
But  if  the  first  attack  is  manic,  it  is  nearly  always  fol- 
lowed by  a  lucid  interval,  rarely  by  a  depressive  phnse. 
The  so-called  mixed  states,  as  a  rule,  do  not  occur  before 
several  depressive  or  manic  attacks  have  preceded. 

The  duration  of  the  attacks  varies  from  a  few  days 
to  several  years,  and  that  of  the  lucid  intervals  from  a 
few  days  to  a  great  number  of  years.  As  a  rule  the  at- 
tacks last  from  6  to  12  months.  The  early  intervals  are 
longer  than  the  later  ones.  In  the  intervals  the  mental 
condition  of  the  patients  is  usually  normal,  or  at  least 
appears  to  be  so.     But  sometimes,  especially  later  in  the 


SPECIAL  PATHOLOGY  241 

disease,  there  occur  in  the  intervals  short  periods  of 
moderate  exaltation,  irritability,  and  restlessness,  or  of 
dejection  and  inactivity. 

The  prognosis  of  recurrent  insanity  is  favorable 
with  regard  to  the  single  attacks,  but  unfavorable  as  to 
recurrence  of  the  disease.  The  first  attacks  ordinarily 
end  in  complete  recovery,  but  later  attacks  leave  behind 
some  mental  enfeeblement.  The  danger  of  pronounced 
mental  deterioration,  of  secondary  dementia,  is  greatest 
when  the  attacks  are  very  frequent  or  prolonged. 

A  patient  may  have  an  attack  of  mania  or  melan- 
cholia, recover  completely,  and  remain  sane  all  through 
the  rest  of  his  life.  Whether  such  a  case  is  to  be  classed 
with  recurrent  insanity — manic-depressive  insanity — or 
not,  is  merely  a  theoretical  question.  Practically  it  is 
of  importance  that  in  a  given  case  of  mania  or  melan- 
cholia with  no  history  of  previous  attacks  the  physician 
should  be  guarded  in  the  prognosis,  bearing  in  mind 
the  possibility  of  a  recurrence  of  the  disease,  especially 
when  a  strong  hereditary  taint  can  be  established  in  the 
patient's  family.  In  cases,  however,  in  which  there  is  a 
history  of  previous  attacks,  the  physician  is  undoubtedly 
dealing  with  recurrent  insanity  and  may  predict  other  at- 
tacks with  a  fair  degree  of  probability. 

Differential  Diagnosis.  When  a  history  of  previ- 
ous attacks  is  obtained,  the  diagnosis  offers  no  difficulty. 
The  disease  has  to  be  differentiated  from  paretic  insanity 
and  dementia  prgecox,  in  which  psychoses  there  may  also 
be  excitative  and  depressive  stages  separated  by  lucid  in- 
tervals. In  recurrent  insanity  early  indications  of  intel- 
lectual deterioration  are  lacking.  The  delusions  are  not 
as  absurd  in  character  as  in  paretic  insanity  and  dementia 
praecox.     In  general  paresis  there  are  characteristic  physi- 


242  PSYCHE 

cal  symptoms,  such  as  faulty  reaction  of  the  pupils,  de- 
fective articulation,  etc.  Pronounced  stereotypy,  man- 
nerism, negativism,  automatism,  etc.,  speak  rather  for 
dementia  prgecox  than  for  recurrent  insanity.  In  the 
latter  disease  the  patients  respond  more  readily  to  exter- 
nal stimuli,  and,  while  in  a  manic  phase,  are  more  tract- 
able than  in  the  former.  Mild  forms  of  manic-depressive 
insanity  may  be  taken  for  phrenasthenia.  But  in  this 
disease  the  patients  have  the  insight  into  the  morbidity  of 
their  mental  condition. 

Therapy.  Preventative  treatment  is  very  important 
in  recurrent  insanity.  Patients  having  gone  through  an 
attack  of  mania  or  melancholia  should  lead  a  quiet  life, 
free  from  any  excitation.  Marriage  is  contraindicated 
in  cases  of  doubtless  recurrent  insanity.  The  treatment 
of  the  individual  attacks  has  been  outlined  in  the  chapters 
on  mania  and  melancholia. 


Chapter   XCIII. 
EPILEPTIC  INSANITY. 

Epilepsy  is  frequently  productive  of  mental  disorder. 
It  leads  to  insanity  in  two  ways.  In  the  first  place,  the 
injurious  influence  exerted  on  the  mind  by  the  epileptic 
attacks  causes  mental  deterioration.  Secondly,  the  epi- 
leptic attacks  are  sometimes  replaced  by  spells  of  mental 
alienation,  the  so-called  psychic  equivalents  of  the  epileptic 
attacks. 

The  first  form  of  epileptic  insanity  appears  as 
feeble-mindedness.  Shortly  after  every  epileptic  attack 
the   patient   has   difficulty  in   remembering  things   and 


SPECIAL  PATHOLOGY  243 

events,  and  this  disturbance  of  memory  is  associated  with 
some  impairment  of  the  understanding.  This  state  of 
mental  weakness  is  transitory.  But  when  the  attacks  recur 
frequently,  it  becomes  permanent  and  represents  epileptic 
insanity  in  the  form  of  feeble-mindedness. 

Regarding  the  psychic  equivalents  of  the  epileptic 
attacks,  preepileptic  insanity  and  postepileptic  insanity  are 
distinguished.  An  analysis  of  the  epileptic  attack  will 
more  clearly  explain  the  nature  of  the  psychic  equivalent. 
The  epileptic  attack  may  be  completely  or  incompletely 
developed,  and  mild  as  well  as  severe  attacks  may  occur 
in  the  same  patient.  The  typical  complete  epileptic  at- 
tack begins  with  the  so-called  aura,  consisting  in  peculiar 
sensations  which  warn  the  patient  of  the  approach  of  the 
next  and  severer  stages  of  the  attack.  The  patient  has 
still  time  to  retreat  to  a  place  of  shelter  and  safety  and 
to  put  dangerous  objects  out  of  the  way.  The  aura  is 
succeeded  by  feelings  of  anxiety  associated  with  ter- 
rifying hallucinations  and  illusions,  as  hearing  the  thun- 
dering of  cannons,  seeing  burning  structures,  beholding 
bitter  enemies  in  people  standing  near  by,  etc.  Complete 
loss  of  consciousness  and  general  convulsions  follow 
thereupon.  The  patient  falls  down,  and  tonic  and  clonic 
spasms  arise  in  various  muscle  groups.  The  spasms  of 
the  respiratory  muscles  hinder  the  respiration,  causing 
cyanosis,  especially  visible  on  neck  and  face.  The  mouth 
is  almost  closed,  the  tongue  is  caught  between  the  teeth, 
and  the  lips  become  soon  covered  with  foam,  the  saliva 
being  drawn  in  and  out  between  them.  After  a  while 
the  convulsions  gradually  subside  and  finally  cease.  The 
unconsciousness,  however,  continues  for  some  time  and 
passes  into  a  sleeplike  state  from  which  the  patient  sooner 


244  PSYCHE 

or  later  awakes  with  no  recollection  of  what  has  trans- 
pired. 

These  four  stages  of  the  epileptic  attack  are  not 
always  well  marked.  The  aura  and  the  stage  of  anxiety 
may  be  very  short.  The  patient  has  hardly  become  aware 
of  the  preliminary  disagreeable  sensations  when  he  is 
seized  with  the  convulsions.  Sometimes  the  attack  stops 
short  in  a  certain  stage.  Thus  the  patient,  overcome  by 
the  unpleasant  sensations  of  the  aura,  may  recover  imme- 
diately. At  another  time  a  state  of  semi-consciousness 
follows  a  short  aura  without  the  intervention  of  con- 
vulsions. 

In  the  semiconscious  state  just  mentioned  the  patient 
is  entirely  unreliable.  Driven  by  terrifying  hallucina- 
tions, he  is  apt  to  commit  the  greatest  atrocities.  It  may 
be  added  here  that  the  homicides  perpetrated  by  the  epilep- 
tics are  characterized  by  extreme  brutality  and  by  lack 
of  motive.  The  semiconsciousness  following  immediately 
after  a  short  and  imperceptible  aura  may  last  very  long, 
several  days.  It  represents  a  psychic  equivalent  of  the 
epileptic  attack.  The  abnormal  mental  condition  just 
sketched  constitutes  preepileptic  insanity. 

Sometimes  the  attack  is  developed  as  far  as  the  stage 
of  convulsions,  and  after  they  have  ceased,  the  patient 
rises  too  early  before  having  recovered  full  consciousness, 
and  begins  to  walk  about  in  a  semiconscious  condition. 
The  latter  may  last  days  and  weeks,  and  during  this 
time  the  patient  may  perform  all  kinds  of  misdeeds. 
This  mental  disorder  of  the  epileptic  patient  is  designated 
as  postepileptic  insanity. 

In  all  exactness  the  psychic  equivalent  of  the  epileptic 
attack  is  but  a  protracted  stage  of  the  attack. 

The  psychic  equivalents  of  the  epileptic  attacks  oc- 


ifiiiw 


SPECIAL  PATHOLOGY  245 

cur  chiefly  in  epilepsy  commencing  after  the  completion 
of  the  general  development,  i.  e.,  after  the  age  of  20 
years^  and  especially  in  those  cases  in  which  a  cranial  in- 
jury has  furnished  the  cause  of  the  epilepsy. 

It  is  a  peculiarity  of  the  epileptic  attacks,  of  the  in- 
complete as  well  as  the  complete  ones,  that  they  may  be 
brought  on  through  certain  sensitive  areas  of  the  body. 
After  Brown-Sequard  had  succeeded  in  artificially  pro- 
ducing epilepsy  in  animals,  the  observation  has  been  made 
that  in  man  a  sensitive  scar,  especially  of  the  skull,  may 
become  the  source  of  epileptic  attacks.  That  the  latter 
are  periodic,  although  the  irritative  influence  of  the  scar 
is  constant,  may  be  explained  in  the  following  way.  The 
sensitive  scar  increases  the  excitability  of  the  patient. 
Any  insignificant  incidental  irritation  suffices,  therefore, 
to  produce  an  attack,  as  a  psychical  excitement,  slight 
overfilling  of  the  stomach,  knocking  against  an  object,  etc. 

The  treatment  of  epileptic  insanity  is  symptomatic. 
Care  must  be  taken  that  the  patients  do  not  harm  them- 
selves and  others.  The  extirpation  of  a  sensitive  scar 
which  may  form  the  exciting  cause  of  the  epileptic  at- 
tacks, is  indicated.  The  psychic  equivalents  are  very 
little  influenced  by  the  bromides. 

Forensic  Consideration.  Epileptics  are  liable  to 
come  into  conflict  with  the  Penal  Code.  The  physician 
ought,  therefore,  to  be  well  informed  about  the  connec- 
tion between  epilepsy  and  crime,  about  the  fact  that  epilep- 
tics are  subject  to  spells  of  impaired  consciousness  during 
which  they  may  commit  various  misdeeds.  When  called 
upon  to  give  an  opinion  in  a  case  of  brutal  homicide, 
unexplained  by  any  motive,  the  physician  should  bear 
in  mind  that  such  crimes  are  characteristic  of  epilepsy. 
A  helpful  hint  is  obtained  when  a  gap  of  memory  can  be 


246  PSYCHE 

demonstrated  in  the  defendant  (p.  66).  For  the  epileptic 
attacks  and  their  psychic  equivalents  leave  gaps  of  mem- 
ory in  the  patient.  The  factor  of  amnesia  ought,  there- 
fore, to  receive  proper  consideration  in  criminal  cases 
where  there  is  suspicion  that  the  defendant  is  an  epileptic. 
He  may  not  know  anything  of  the  crime  accused  of, 
having  committed  it  in  a  semiconscious  state  for  which 
there  is  now  a  gap  of  memory. 

An  epileptic  having  committed  a  punishable  act 
during  a  semiconscious  state  may  be  able  to  give  to  the 
physician  an  exact  description  of  the  details  of  the  of- 
fense. In  such  a  case  the  physician  should  not  exclude 
a  disturbance  of  consciousness  for  the  time  of  the  offense 
because  of  the  apparent  absence  of  amnesia.  For  it  is 
possible  that  the  defendant  is  acquainted  with  the  details 
of  the  offense  because  he  has  learned  them  subsequently 
from  others. 

An  impostor  found  guilty  of  repeated  embezzlement, 
theft,  etc.,  may  pretend  to  have  committed  these  crimes 
in  states  of  unconsciousness.  In  such  an  instance  it  is 
necessary  to  examine  whether  the  unlawful  acts  have 
always  turned  out  to  the  advantage  of  the  perpetrator  or 
have  now  and  then  been  harmful  to  him.  In  the  first 
case  malingery  is  to  be  assumed,  in  the  second  case  epi- 
lepsy is  to  be  taken  into  consideration. 


Chapter  XCIV. 
PARETIC  INSANITY. 

General  paresis,  general  progressive  paralysis,  stands 
in  close  relation  to  lues,  syphilitic  patients  having  a  far 
greater  predisposition  to  paresis  than  those  free   from 


SPECIAL  PATHOLOGY  247 

luetic  infection.  Nevertheless,  some  psychiatrists  have 
held  the  view  that  paresis  does  not  constitute  a  late  luetic 
symptom,  since  in  a  good  many  cases  lues  can  positively 
be  excluded  (p.  115). 

General  paresis  is  chiefly  an  acquired  disease.  It  is 
contracted  through  excesses  in  Baccho  et  Venere  and 
through  overexertion.  Regarding  sexual  indulgence  the 
excesses  themselves  are  not  as  important  an  exciting 
cause  as  the  infection  which  they  occasion. 

General  paresis  occurs  most  frequently  at  the  age  of 
25 — 40  years.  Between  20 — 25  it  is  uncommon,  so  that 
in  a  case  of  this  age,  showing  paretic  symptoms,  lues 
cerebri,  which  resembles  paresis,  has  to  be  taken  into 
consideration.  Under  20  years  of  age  general  paresis  is 
very  rare.  From  40 — 60  it  becomes  rarer  and  rarer,  and 
after  60  it  is  hardly  ever  met  with.  In  psychoses  at  this 
age,  which  are  similar  to  paretic  insanity,  careful  differ- 
entiation from  senile  insanity  should  be  made. 

Paretic  insanity,  as  a  rule,  has  a  longer  precursory 
stage  than  other  psychoses.  This  prodromal  period 
lasts  from  several  months  to  a  year  and  even  longer. 
Some  French  authors  maintain  that  many  patients  pass 
all  their  life  in  the  precursory  stage  of  paretic  insanity. 
But  this  assertion  goes  too  far. 

The  most  important  feature  of  the  precursory  stage 
consists  in  alteration  of  character.  This  symptom  is  not 
indefinite,  vague,  or  hardly  noticeable,  but  is  very  striking. 
The  steadfast  and  upright  man  begins  to  be  dissolute 
and  untrustworthy,  the  good  father  and  faithful  husband, 
to  neglect  his  family  more  and  more.  He  may  become 
infatuated  with  a  woman  of  low  character  and  for  her 
sake  abandon  a  happy  home.  A  prominent  psychiatrist 
relates  a  case  in  which  a  patient  in  the  precursory  stage  of 


248  PSYCHE 

paretic  insanity  told  his  wife  of  his  irresistible  love  for 
one  of  his  factory  girls,  insisting  that  she  be  taken  into 
the  family.  The  symptom  of  alteration  of  character, 
therefore,  does  not  lack  distinctness.  It  shows  itself  also 
in  a  change  of  taste.  The  former  favorite  dishes  are 
refused  by  the  patient,  and  he  greatly  relishes  now  food 
which  he  used  to  dislike. 

The  alteration  of  character  becomes  still  more  con 
spicuous  through  simultaneous  impairment  of  memory. 
The  business  man  always  attentive  of,  and  retaining  in 
mind,  the  most  insignificant  trifles,  becomes  neglectful 
and  forgetful  of  the  most  important  affairs. 

The  vitiation  of  character  is  further  associated  with 
a  weakening  of  intelligence.  This  is  clearly  shown  by 
the  above  example  in  which  a  husband  with  a  sort  of  nai- 
vete wants  his  wife  to  admit  into  her  home  a  woman 
with  whom  he  has  explicitly  asserted  to  be  in  love.  It  is 
quite  characteristic  of  paretic  insanity  that  weakness  of 
the  understanding  appears  already  in  the  initial  stage  of 
the  psychosis  (p.  232). 

In  the  precursory  stage  paretic  patients  render  them- 
selves guilty  of  manifold  extravagances.  Most  of  the 
court  proceedings  in  which  paretics  are  involved  refer 
to  excesses  committed  in  this  stage. 

The  precursory  stage  is  marked  by  various  somatic 
disturbances.  Sleep  is  greatly  impaired.  Frequently  it 
does  not  come  before  the  morning.  Instead,  the  patient 
falls  asleep  at  unusual  times,  for  instance,  while  at  the 
dinner  table.  Now  and  then  the  patient  is  seized  with 
apoplectiform  attacks  marked  by  loss  of  consciousness. 
These  spells  do  not  last  long  and  leave  no  after-effects. 

Motor  disturbances  of  the  precursory  stage  are  slug- 
gish reaction  of  the  pupils,  which  may  be  narrow  or  un- 


SPECIAL  PATHOLOGY  249 

equal,  and  diminution  or  absence  of  the  tendon  reflexes. 
Some  patients  show  increased  reflexes  even  in  advanced 
stages  of  the  disease,  but  in  those  cases  where  the  re- 
flexes are  absent  at  a  later  stage,  they  have  been  dimin- 
ished or  absent  in  the  precursory  stage.  Many  paretic 
patients  present  also  symptoms  of  tabes,  such  as  rigidity 
of  the  pupils,  atactic  gait,  etc.  There  are  also  cases  in 
which  for  years  only  tabetic  symptoms  are  present,  and 
then  paresis  suddenly  supervenes.  In  such  instances  we 
may  speak  of  paresis  .with  a  long  precursory  stage 
marked  by  tabetic  symptoms,  or  of  tabes  which  has 
been  followed  by  paresis.  Which  view  is  correct  must  be 
left  undecided. 

Sensory  disturbances  are  common  in  the  precursory 
stage.  Many  a  patient  goes  through  all  kinds  of  hydro- 
therapeutic  and  other  procedures  to  cure  his  "rhematism," 
and  at  last  he  begins  to  show  distinct  symptoms  of  general 
paresis.  Impainnent  of  vision,  for  a  long  time  attributed 
to  some  cause  or  other,  as  to  nicotine  poisoning,  is  finally 
recognized  as  a  paretic  symptom. 

Under  certain  conditions  the  precursory  stage  is  very 
short  or  lacking  altogether.  When  a  syphilitic  patient, 
for  instance,  receives  a  severe  trauma  of  the  skull,  he 
may  directly  become  a  victim  of  general  paresis,  a  pre- 
cursory stage  being  hardly  noticeable.  But  in  the  absence 
of  such  a  coarse  injury  to  the  brain  a  precursory  stage 
is  not  wanting. 

The  precursory  stage  is  succeeded  by  an  attack  of 
melancholia  or  of  mania.  After  several  such  periods  of 
excitement  follows  the  final  stage  of  dementia.  In  these 
periods,  which  may  be  separated  by  remissions,  melan- 
cholia and  mania  alternate  or  are  irregularly  repeated. 


250  PSYCHE 

In  some  instances,  however,  the  precursory  stage  passes 
uninterruptedly  into  the  dementia  paralytica. 

The  melanchoHc  excitement  of  paretic  insanity  re- 
sembles ordinary  melancholia,  but  is  distinguished  by  the 
absurdity  of  the  delusions  of  self -depreciation  (p.  55). 
While  in  ordinary  melancholia  the  patient  would  say  he 
is  sinful,  he  is  unworthy  of  nourishment,  eternal  damna- 
tion will  be  his  lot,  the  world  will  perish  because  of  his 
wickedness,  etc.,  the  paretic  melancholic  says  he  has 
shrivelled  to  the  size  of  a  pigeon,  he  does  not  exist  at  all, 
the  world  has  already  perished  on  account  of  his  sins,  etc. 
These  entirely  nonsensical  delusions  are  quite  character- 
istic of  general  paresis. 

During  the  melancholic  stage  the  somatic  disturb- 
ances make  further  progress.  A  defect  of  articulation 
becomes  manifest,  the  patient  being  unable  to  pronounce 
certain  words.  In  this  respect  faulty  pronunciation  of 
difficult  words  is  not  of  great  importance.  What  is 
more  significant  is  that  the  patient  mutilates  every-day 
words,  but  repeats  them  correctly  when  his  attention  is 
called  to  the  mistake.  An  uneducated  person,  many  a 
time,  does  not  enunciate  well  complicated  words,  such  as 
artillery,  electricity,  etc.  If,  however,  a  patient  corrupts 
plain  words  when  speaking  in  the  usual  manner,  but  pro- 
nounces them  without  fault  when  he  pays  attention  to 
every  word,  a  valuable  symptom  for  the  diagnosis  general 
paresis  is  obtained.  Something  similar  holds  good  as 
to  writing.  When  the  paretic  patient  is  not  more  atten- 
tive to  his  writing  than  ordinarily,  it  may  be  defective, 
some  strokes  or  whole  syllables  and  words  being  omitted. 
He  is  unable  to  write  certain  frequent  words,  as  his  own 
name,  at  one  stretch.  But  when  he  is  very  careful  of  his 
writing,  it  may  be  fairly  good.     The  slowness  and  care 


SPECIAL  PATHOLOGY  251 

the  patient  has  to  use  in  order  to  avoid  mistakes  and 
omissions  in  writing,  furnish  an  important  paretic 
symptom. 

The  melanchoHa  is  followed,  sometimes  preceded, 
by  a  period  of  maniacal  excitement.  As  a  rule,  it  is  in 
such  a  stage  that  paretic  patients  are  committed  to  the 
insane  asylum.  The  mania  of  paretic  insanity  differs 
from  ordinary  mania  by  the  absurdity  of  the  delusions  of 
grandeur.  They  are  not  explained  in  any  way,  contain 
a  palpable  nonsense,  are  full  of  contradictions,  and  in 
great  contrast  with  the  patient's  education  (p.  55).  Now 
he  maintains  to  be  the  emperor,  now  the  pope  or  the 
Lord  himself.  He  possesses  billions  given  to  him  by 
the  emperor  of  China.  Questioned  for  what  meritorious 
feats  the  emperor  has  bestowed  upon  him  so  munificent 
a  gift,  he  answers  he  is  himself  the  emperor  of  China. 
Another  paretic  maniac  would  say  his  body  consists  of 
precious  stones,  he  has  bones  of  diamonds,  etc.  When 
a  maniac  asserts  to  possess  billions,  absurd  delusion  of 
grandeur  is  not  to  be  assumed  at  once,  but  he  must  be 
asked  how  he  obtained  such  wealth.  A  non-paretic 
maniac  will  give  some  explanation. 

Now  and  then  the  mania  of  paretic  insanity  is  in- 
terrupted by  the  so-called  paralytic  attacks.  Usually  oc- 
curring in  a  maniacal  stage,  they  have  an  apoplectiform 
or  epileptiform  character.  The  patients  recover  from  these 
spells  in  a  short  time,  a  few  days,  and  then  the  mania 
continues. 

The  occurrence  of  remissions  in  the  course  of  paretic 
insanity  is  of  special  importance.  The  maniacal  or  mel- 
ancholic excitement  subsides,  the  patient  becomes  calm. 
With  the  cessation  of  the  morbid  affective  state  the  delu- 
sions also  disappear.     The  patient  recognizes  his  delu- 


252  PSYCHE 

sions  as  such  and  abandons  them.  He  even  admits  that 
he  has  been  mentally  ill,  i.  e.,  he  gains  the  insight  into  the 
disease  (p.  129).  But  the  rule  that  the  rising  conscious- 
ness of  having  been  mentally  ill,  constitutes  a  sign  of 
convalescence,  does  not  hold  good  in  the  remissions  of 
paretic  insanity.  A  remission  in  this  psychosis  is  far 
from  convalescence.  A  hint  that  during  such  a  stage  the 
mental  disease  has  merely  made  a  transitory  standstill,  is 
furnished  by  the  continuation  of  many  motor  disturb- 
ances. The  pupillary  reaction  is  insufficient  or  absent, 
the  articulation  and  writing  are  defective,  the  gait  is  un- 
steady. The  patient  becomes  fatigued  quickly,  a  short 
walk  makes  him  feel  the  need  of  sitting  down  and  resting 
his  weary  legs.  These  paretic  symptoms  are  much  less 
noticeable  in  a  remission  than  in  the  melancholic  and 
maniacal  stages.  For  the  patient  has  become  quiet  and 
is,  therefore,  better  able  to  direct  his  attention  to  these 
functions.  But  these  motor  disturbances  do  not  dis- 
appear entirely  during  a  remission. 

The  duration  of  the  remissions  varies.  Rarely  a  re- 
mission extends  over  a  longer  period  than  three  years, 
but  remissions  even  of  20  years'  duration  do  occur.  In 
a  case  in  which  the  patient  has  died  in  a  remission  after 
it  had  lasted  for  a  very  long  time,  we  may  speak  of  re- 
covery from  general  paresis.  But  as  a  general  rule,  re- 
covery from  this  psychosis  is  not  to  be  counted  upon. 

The  remission  comes  to  an  end  through  the  out- 
break of  an  acute  exacerbation,  which  is  usually  caused 
by  the  patient  having  overestimated  his  powers  and  taken 
upon  himself  too  difficult  tasks.  The  exacerbation  begins 
all  of  a  sudden  in  the  form  of  maniacal  or  melancholic  ex- 
citement and  makes  the  patient  decline  rapidly.  A  paretic 
patient,   therefore,   must   be   dissuaded    from   resuming. 


SPECIAL  PATHOLOGY  253 

during  a  remission,  his  former  hard  occupation.  For 
the  quieter  a  Hfe  he  leads,  the  longer  the  remission  would 
last.  But  even  a  patient  who  enjoys  perfect  rest  is  not 
spared  a  recrudescence  of  the  disease. 

The  recurrence  of  acute  symptoms  after  a  remission 
exhausts  the  patient  more  than  the  first  stage  of  excite- 
ment. The  paralytic  attacks  become  more  and  more  fre- 
quent, and  the  patient  usually  passes  soon  into  the  final 
stage  of  dementia. 

The  dementia  of  paretic  insanity  is  not  a  stable  con- 
dition. The  patient  proceeds,  at  a  rapid  pace,  on  his  jour- 
ney towards  the  fatal  end.  He  soon  becomes  unable  to 
walk,  stand,  sit  upright,  and  swallow.  Artificial  feeding 
has  to  be  employed  invariably.  At  times,  even  without 
the  intervention  of  paralytic  attacks,  (p.  251),  he  falls 
into  states  of  great  weakness  which  last  several  days. 
The  feeding  becomes  more  and  more  diflficult,  the  nutri- 
tion insuf^cient,  and  through  general  exhaustion  or  some 
intercurrent  disease  the  patient's  wretched  life  reaches 
its  termination.  The  autopsy  reveals  considerable  patho- 
logical changes  in  the  brain  cortex. 

Prognosis  and  Differential  Diagnosis.  Because 
of  the  prognosis  the  differential  diagnosis  of  paretic  insan- 
ity is  of  great  importance.  When  the  physician  has  con- 
vinced himself  that  a  mental  malady,  as  melancholia  or 
mania,  is  based  on  general  paresis,  he  may  put  down  the 
prognosis  as  lethal,  and  declare  to  the  patient's  relatives 
that  cases  of  recovery  from  paretic  insanity  are  so  rare 
that  recovery  is  hardly  to  be  taken  into  consideration. 

Paretic  insanity  is  distinguished  by  its  peculiar  pre- 
cursory stage.  A  similar  prodromal  period  does  not  oc- 
cur in  any  other  psychosis.  Mania  and  melancholia  in 
the  course  of  paresis  are  characterized  by  the  absurdity 


254  PSYCHE 

of  the  delusions  of  grandeur  and  of  self -depreciation 
respectively.  Motor  disturbances,  such  as  rigidity  of  the 
pupils,  impairment  of  articulation  and  writing,  unsteady 
gait,  etc.,  exclude  all  doubt  of  general  paresis. 

It  does  occur  that  an  insane  patient  succumbs  under 
paretic  symptoms,  although  in  the  beginning  of  the  psy- 
chosis paresis  could  not  be  demonstrated.  In  such  a  case 
it  is  possible  that  we  are  dealing  with  a  psychosis  to 
which  paresis  has  supervened,  or  with  paretic  insanity 
which  did  not  commence  in  the  typical  manner.  The 
first  assumption  is  more  probable.  For  there  is  no  known 
reason  why  an  insane  person,  as  well  as  a  sane  one,  should 
not  develop  general  paresis. 

Therapy. — Antiluetic  treatment  has  not  proved  to 
be  of  beneficial  effect  on  the  course  of  paretic  insanity. 
In  some  instances  it  brings  about  a  slight  improvement, 
but  the  latter  is  only  transitory,  and  the  morbid  process 
is  afterwards  accelerated  in  consequence  of  the  weaken- 
ing influence  of  the  antiluetic  procedures. 

A  good  deal,  however,  can  be  accomplished  to  pro- 
long the  patient's  life.  If  a  paretic  patient  succumbs  after  a 
comparatively  short  illness,  the  suspicion  is  justified  thai 
the  treatment  has  been  neglected,  that  he  has  not  been 
properly  protected  against  the  numerous  dangers  his 
disease  is  attended  with.  Owing  to  deficiency  of  deglu- 
tition, foreign  material  may  be  drawn  in  the  deeper  air 
passages  and  pneumonia  may  result.  The  patient  may 
burn  his  oesophagus  and  stomach  by  swallowing  too  hot 
food,  become  affected  with  cystitis  through  disturbance 
of  the  function  of  the  bladder,  and  contract  phlegmons 
from  slight  sores.  All  these  dangers  can  be  obviated  by 
careful  circumspection.  A  paretic  patient  with  deficiency 
of  deglutition  must  be  assisted  while  eating  or  even  arti- 


SPECIAL  PATHOLOGY  255 

ficially  fed,  especially  when  he  has  bronchitis,  because 
during  an  attack  of  coughing  the  danger  of  drawing  par- 
ticles of  food  into  the  lungs  is  very  great.  The  evacuation 
of  bowels  and  bladder  has  to  be  regulated  and  watched. 
The  most  insignificant  lesion  of  the  skin  must  not  be  dis- 
regarded, but  carefully  treated. 

Great  difficulty  of  treatment  is  encountered  during 
long  lasting  paralytic  attacks.  One  epileptiform  or  apo- 
plectiform attack  may  follow  the  other,  so  that  the  patient 
remains  in  an  unconscious  state  for  many  days.  It  is 
then  necessary  to  introduce  into  the  system  a  sufficient 
quantity  of  fluid.  This  should  not  be  done  per  os  because 
of  the  danger  of  aspiration  into  the  lungs,  but  the  fluid 
should  be  given  per  rectum,  very  slowly  and  under  slight 
pressure,  to  prevent  its  being  ejected. 

Forensic  Consideration.  The  paretic  patient  may 
become  involved  in  civil  and  criminal  suits  as  early  as  the 
precursory  stage.  Penal  acts  may  be  committed  by  the 
patient  in  a  stage  of  maniacal  excitement  and  during  a 
remission.  Civil  suits  at  the  precursory  stage  arise  from 
foolish  extravagance  of  the  patient  which  results  to  the 
detriment  of  his  family  and  of  others.  Criminal  acts  at 
this  period  are  such  as  perjury  due  to  failing  memory, 
forgery,  poisoning  of  the  wife  out  of  illicit  love  for  an- 
other woman,  etc.  In  a  maniacal  stage  paretic  patients 
commit  acts  of  violence  and  render  themselves  guilty  of 
theft  owing  to  the  delusion  that  everything  belongs  to 
them  (p.  89),  etc.  The  misdeeds  perpetrated  during  a 
remission  are  similar  to  those  of  the  precursory  stage, 
especially  when  the  patients  resume  their  former  occupa- 
tions. 

A  difficult  question  for  the  physician  to  decide  is 
whether  or  not  a  paretic  patient  may  be  permitted  to  en- 


256  PSYCHE 

joy,  during  a  remission,  the  right  to  the  control  of  his 
estate.  The  physician  will  find  it  difficult  to  convince 
the  court  that  the  patient  ought  to  be  adjudged  incompe- 
tent on  the  ground  that  he  is  only  apparently  sane,  and 
manifest  insanity  may  set  in  again  in  full  force  at  any 
moment.  For  the  court  would  hardly  appreciate  the  sig- 
nificance of  a  sluggish  pupillary  reaction  and  other  slight 
motor  disturbances  still  noticeable  in  the  patient,  but 
would  rather  consider  such  signs  as  trifles  not  furnishing 
sufficient  cause  to  declare  the  patient  incompetent. 

In  some  cases  it  is  not  requisite  to  divest  paretic 
patients,  during  remissions,  of  the  right  to  the  control 
of  their  estates,  in  the  same  way  as  it  is  sometimes  not 
necessary  to  take  away  this  right  from  secondarily  insane 
patients,  for  instance,  when  their  fixed  delusions  have  no 
relation  whatsoever  with  their  financial  afifairs.  A  pa- 
retic patient  in  a  remission  may  be  allowed  to  manage 
his  revenue  if  he  derives  his  livelihood  from  a  monthly 
pension.  Leaving  race  deterioration  out  of  the  question, 
we  may  even  allow  him  to  contract  a  marriage.  If  the 
bride-to-be  and  the  patient  have  been  warned  and  made  to 
understand  that  a  recurrence  of  the  disease  is  to  be  ex- 
pected, and  nevertheless  they  do  not  desist  from  the  mari- 
tal union,  the  prospective  bride,  for  instanc,  insisting  that 
she  wants  to  be  to  her  beloved  a  faithful  nurse  in  his 
illness,  the  consent  to  their  marriage  cannot  be  justly 
withheld. 

If  a  paretic  patient  harbors  a  grudge  against  his  rel- 
atives for  having  caused  his  commitment  to  the  insane 
asylum  or  for  any  other  reason,  he  should  not  be,  during 
a  remission,  in  charge  of  his  property.  For  he  is  apt  to 
disinherit  them  or  sell  everything  he  possesses  and  escape 
with  the  proceeds. 


SPECIAL  PATHOLOGY  257 

Chapter  XCV. 
ALCOHOLIC  INSANITY. 

The  consumption  at  one  time  of  a  large  quantity  of 
alcohol  produces  a  state  of  intoxication  which,  in  all 
exactness,  represents  an  acute  psychosis.  The  abuse  of 
alcohol  extending  over  a  long  period,  on  the  other  hand, 
brings  about  a  condition  which  is  designated  as  ^'chronic 
alcoholism.''  The  latter  comprises  a  complex  of  symp- 
toms in  the  sphere  of  the  central  nervous  system  and 
some  other  organs. 

The  noxiousness  of  the  various  alcoholic  beverages 
is  proportionate  to  the  percentage  of  alcohol  and  the 
amount  of  impurities,  such  as  the  fusel  oils,  which  they 
contain.  Beer  is,  therefore,  less  injurious  than  wine,  light 
wine  less  than  heavy  wine,  and  brandy  and  whiskey  more 
injurious  than  wine.  Li  cold  regions,  combined  with 
much  physical  exertion  and  copious  food,  alcohol  is  com- 
paratively well  borne. 

The  manifestations  of  chronic  alcoholism  result  from 
the  deterioration  of  many  organs.  Alcohol  irritates  the 
upper  part  of  the  alimentary  tract,  causing  chronic  ca- 
tarrh of  the  stomach — vomitus  matutinus.  It  affects  liver 
and  kidneys,  producing  cirrhosis  of  these  organs — chronic 
hepatitis  and  nephritis.  The  injurious  influence  of  alco- 
hol on  the  nervous  system  is  shown  by  many  nervous 
symptoms,  and  these  mainly  constitute  the  chronic  alco- 
holism. 

An  early  symptom  of  chronic  alcoholism  is  the  pecu- 
liar depravity  of  character.  The  drinker  neglects  his 
family,  is  unkind  and  rude  to  his  wife,  indifferent  to  his 
business  affairs,  derelict  in  the  duties  of  his  vocation. 


258  PSYCHE 

He  has  no  feeling  of  honor,  no  self-respect.  He  is  not 
fastidious  in  the  choice  of  his  companions.  An  alcohoHc 
of  the  best  family  and  of  high  position  will  not  be 
ashamed  to  tope  in  company  with  individuals  of  the  scum 
of  society.  All  these  improprieties  constitute  the  pecu- 
liar alcoholic  depravity  of  character.  The  deeper  the 
patient  sinks,  the  more  marked  it  becomes. 

The  habitual  drinker  is  very  irritable,  sensitive,  vio- 
lent, and  indifferent  to  his  own  life.  In  a  fit  of  excite- 
ment he  is  apt  to  assault  anybody  crossing  his  way,  and 
the  subsequent  annoyance  at  this  impulsive  act  is  suffi- 
cient reason  for  him  to  commit  suicide. 

The  alcoholic  gets  up  in  the  morning  with  a  certain 
abhorrence  of  his  existence.  The  thought  of  having  to 
perform  his  daily  work  renders  him  morose  and  weary 
of  life.  This  sour  temper  does  not  pass  away  before  he 
has  taken  recourse  to  his  habitual  stimulant,  a  glass  of 
wine  or  brandy. 

It  is  difficult  to  establish  the  limit  where  chronic  al- 
coholism begins.  One  who  consumes  a  great  deal  of 
alcohol  is  not  necessarily  affected  with  this  morbid  condi- 
tion. An  individual  with  a  strong  constitution  can  stand 
a  great  deal  of  alcohol,  another  one  with  a  weak  constitu- 
tion manifests  morbid  symptoms  at  a  much  smaller  con- 
sumption of  alcohol.  The  finest  reagent  to  determine  the 
beginning  of  chronic  alcoholism  is  inability  to  work.  An 
alcoholic  who  awakes  in  the  morning  feeling  ill  at  ease, 
morose,  unable  to  work,  and  has  first  to  take  some  wine 
or  brandy  to  get  rid  of  this  ill  humor,  is  suffering  from 
chronic  alcoholism.  A  drinker  who  cannot  dispense  with 
alcohol  without  manifesting  weakness,  or,  as  the  technical 
term  is,  without  symptoms  of  abstinence,  is  sick  with 
chronic  alcoholism.     A  similar  condition  is  met  with  in 


SPECIAL  PATHOLOGY  259 

chronic  poisoning  with  morphine  and  nicotine.  These 
patients  also  cannot  miss  their  habitual  stimulants  without 
showing  symptoms  of  weakness.  The  chief  criterion  for 
the  presence  of  chronic  alcoholism  is,  therefore,  the  ap- 
pearance of  certain  symptoms  of  abstinence  when  the  use 
of  alcohol  is  interrupted. 

An  important  symptom  of  chronic  alcoholism  is  great 
reduction  of  the  will  power. 

All  psychoses  due  to  alcohol  poisoning  presuppose 
chronic  alcoholism,  i,  e.,  one  who  becomes  mentally  ill 
through  the  abuse  of  alcohol  has  been  affected  with 
chronic  alcoholism  for  some  time  past.  In  all  exactness, 
the  latter  is  also  a  mental  disease  as  shown  by  the  great 
diminution  of  will  power  characteristic  of  the  alcoholics. 
They  clearly  see  that  they  are  steering  towards  the  abyss 
by  continuing  the  abuse  of  alcohol,  and  yet  they  lack  the 
necessary  strength  of  will  to  abandon  it.  Whether  a  psy- 
chosis proper  supervenes  depends  upon  accidents  and  cir- 
cumstances. The  psychoses  most  common  in  alcoholics 
are  delirium  tremens,  hallucinatory  insanity,  epileptiform 
insanity,  primary  insanity. 

Delirium  breaks  out  suddenly.  When,  for  instance, 
a  drinker  is  arrested  and  put  into  prison  where  he 
receives  no  alcohol,  delirium  tremens  may  set  in  over 
night.  Or  when  a  drinker,  seized  with  an  acute  disease, 
is  brought  into  the  hospital  where  nobody  even  knows  that 
he  is  addicted  to  alcohol,  delirium  tremens  may  follow 
quickly.  The  latter  is  a  so-called  delirium  of  abstinence, 
i.  e.,  it  is  caused  by  withholding  the  alcohol  from  the 
habitual  drinker.  But  there  is  also  a  delirium  potatorum 
caused  by  exaggeration  of  the  usual  consumption  of  alco- 
hol. At  some  occasion  the  drinker  may  go  far  beyond 
his  ordinary  limit,  consuming  at  one  time  an  excessive 


26o  PSYCHE 

amount  of  alcohol,  which  transgression  may  bring  on  an 
attack  of  delirium. 

Delirium  tremens  potatorum  resembles  the  delirium 
described  before  (Ch.  "jy,  p.  185).  The  delirious  alco- 
holic hallucinates  vividly  in  several  senses.  His  visual 
hallucinations  are  quite  characteristic.  He  sees  many 
small  objects  in  lively  motion  or  approaching  towards  him, 
such  as  spiders,  beetles,  mice,  rats,  little  men  dancing, 
etc.  Delirium  tremens  is  of  shorter  duration  than  other 
deliria.  In  a  comparatively  short  time,  8  to  10  days,  the 
patient  recovers  completely.  \i  however  delirium  tre- 
mens be  frequently  repeated,  the  duration  of  the  attacks 
becomes  longer  and  finally  a  state  of  permanent  mental 
enfeeblement  may  ensue. 

More  rapidly  alcoholics  advance  towards  mental  de- 
cay when  they  become  affected  with  epilepsy. 

Hallucinatory  insanity  is  a  frequent  psychosis  of  the 
alcoholics.  Unlike  in  delirium,  consciousness  is  not 
disturbed  in  hallucinatory  insanity.  The  patient  is  col- 
lected, recognizes  his  surroundings,  and  is  well  aware  of 
what  is  going  on  around  him.  The  hallucinations  cause 
delusions  which  are  quite  characteristic.  The  alcoholic 
imagines  that  he  is  being  deceived  in  his  marital  rights, 
that  rivals  steal  nightly  into  his  home  to  carry  on  illicit 
relations  with  his  wife.  Controlled  by  such  delusions, 
he  walks  at  night  about  his  house,  weapon  in  hand,  as- 
saults anybody  crossing  his  way,  searches  the  corners  and 
closets  of  his  room,  stabs  a  knife  into  the  bed,  shoots  out 
of  the  window  at  passers-by,  fancying  them  to  be  his 
rivals  in  favor  with  his  wife.  These  eccentricities  con- 
stitute the  peculiar  alcoholic  delusions  of  jealousy. 

Alcoholics  sometimes  become  mentally  ill  under  the 


SPECIAL  PATHOLOGY  261 

clinical  picture  of  paranoia  with  delusions  of  furtherance 
and  grievance  (Ch.  75,  p.  176). 

Differential  Diagnosis.  When  it  is  known  that 
abuse  of  alcohol  has  preceded  the  psychosis  to  be  deter- 
mined and  the  characteristic  alcoholic  depravity  of  char- 
acter can  be  established,  the  diagnosis  alcoholic  insanity 
is  assured.  Drinkers  may  be  confounded  with  those  af- 
fected with  intolerance  of  alcohol.  There  are  individuals 
who  can  not  stand  alcohol,  so  that  even  a  moderate  con- 
sumption of  spirituous  liquors  produces  in  them  symptoms 
similar  to  those  met  with  in  excessive  drinkers. 

Forensic  Consideration.  Owing  to  great  irritabil- 
ity, alcoholics  are  apt  to  commit  murder  or  other  out- 
rages at  the  slightest  provocation.  It  is  characteristic 
that  after  the  accomplishment  of  such  violent  acts  they 
attempt  suicide.  Delusions  of  jealousy  may  cause  the 
drinker  to  kill  his  wife  or  a  presumptive  rival.  Neglect 
of  the  duties  of  his  office  may  also  bring  him  in  collision 
with  the  Penal  Code. 

Therapy.  The  means  at  the  disposal  of  the  physi- 
cian to  cure  chronic  alcoholism  are  insufficient  for  the 
reason  that  he  is  rarely  in  a  position  to  have  the  drinker 
deprived  of  his  liberty  for  such  length  of  time  as  would 
be  necessary  to  disaccustom  him  from  the  habitual  use  of 
alcohol.  Ordinarily  an  alcoholic  can  be  legally  committed 
into  an  asylum  only  when  it  is  possible  to  have  him  ad- 
judged insane.  But  this  is  seldom  the  case.  For,  although 
one  day  the  drinker  is  irritable,  morose,  weary  of  life,  and 
loath  to  work,  the  next  day  he  is  discreet,  cheerful, 
amiable,  and  in  a  clever  manner  he  knows  how  to  conceal 
or  excuse  his  intemperance,  so  that  the  court  does  not 
find  sufficient  cause  for  adjudging  him  insane. 

To  try  to  exert  a  moral  influence  upon  the  drinker, 


262  PSYCHE 

to  demonstrate  to  him  that  he  will  ruin  himself  by  con- 
tinuing the  abuse  of  alcohol,  would,  from  a  theoretical 
point  of  view,  seem  to  be  salutary.  But  practically  all 
endeavors  to  reform  the  alcoholic  by  moral  persuasion 
fail  because  of  his  great  weakness  of  will  power.  When 
he  is  committed  into  the  asylum,  he  recognizes  after  a 
comparatively  short  time  that  he  has  brought  misfortune 
upon  himself  and  his  family,  and  is  all  contrite  in  the  most 
desirable  manner.  By  solemn  promises  he  soon  succeeds 
to  gain  the  confidence  and  favor  of  his  relatives.  The 
latter  take  the  patient  away  from  the  asylum,  maintaining 
that  in  his  excellent  condition  of  health  and  with  such 
sincere  resolutions  to  renounce  the  alcohol,  he  can  safely 
be  trusted  and  restored  to  liberty.  But  he  has  hardly 
familiarized  himself  with  the  newly  regained  freedom 
when  the  old  trouble  commences  again.  Nay,  it  happens 
that  the  drinker  beats  his  wife  on  the  very  day  of  his 
dismissal  from  the  asylum.  Now,  how  is  this  possible? 
Have  all  those  solemn  promises  been  false  and  hypocrit- 
ical ?  No,  the  sudden  change  in  the  patient's  conduct  may 
be  explained  in  another  way.  The  promises  and  resolu- 
tions have  indeed  been  true  and  sincere.  But  after  having 
been  removed  from  the  wholesome  restraint  of  the  asy- 
lum, the  patient,  in  the  first  joy  at  the  regained  liberty, 
begins  to  reason  after  this  manner :  ''One  glass  of  wine 
taken  at  your  liberty  will  not  harm  you."  When  he  has 
once  tasted  alcohol,  his  good  intentions  begin  to  waver, 
due  to  his  weakness  of  will  power.  He  drinks  a  second 
glass  and  a  third  one,  and  so  on,  until  he  becomes  intoxi- 
cated. Now  all  the  good  resolutions  are  thrown  over- 
board. 

It  follows   from  the  above  that  it  is  necessary  to 
detain  the  alcoholic  for  years  in  order  to  effect  a  perma- 


SPECIAL  PATHOLOGY  263 

nent  cure.  In  some  instances  this  is  accomplished  with 
impecunious  drinkers  who  have  been  put  into  prison  for 
some  misdeed.  But  even  in  such  cases  it  has  been  ob- 
served that  drinkers  after  dismissal  from  the  prison  have 
again  become  addicted  to  alcohol. 

Prognosis.  The  prognosis  of  alcoholic  insanity  is 
generally  very  bad,  as  may  be  seen  from  the  preceding  re- 
marks. But  with  regard  to  every  single  psychosis  it  is 
comparatively  favorable.  Delirium  passes  off  promptly, 
so  does  hallucinatory  insanity,  even  epileptic  attacks  cease 
without  leaving  permanent  mental  enfeeblement. 


Chapter  XCVL 
DELIRIUM  ACUTUM. 

Delirium  acutum  is  a  mental  disorder  of  unknown 
origin.  It  seems  to  be  justified,  however,  to  assume  that 
intoxication  of  some  sort  or  other  forms  the  exciting 
cause. 

The  disease  attacks  persons  in  the  prime  of  life  and 
is  characterized  by  a  very  abrupt  onset.  Cases  of  deli- 
rium acutum,  therefore,  are  usually  not  observed  in  the 
insane  asylum,  but  in  private  or  in  the  general  hospital. 

Delirium  acutum  presents  the  following  clinical  pic- 
ture. Without  any  forebodings  a  young  or  middle-aged 
person  is  suddenly  seized  with  great  excitement.  He  be- 
gins to  act  in  a  frantic  manner;  he  tears  his  clothes,  de- 
stroys everything  within  reach,  and  assaults  everybody 
coming  near  him.  We  might  suppose  that  the  patient 
were  suffering  from  an  attack  of  mania.  But  a  day  or 
two  later  it  becomes  noticeable  that  his  consciousness  is 


264  PSYCHE 

considerably  impaired,  that  he  hallucinates  strongly,  that 
his  eyes  lack  the  brilliant,  fresh  look  of  the  maniac,  and 
the  expression  of  his  countenance  betrays  a  serious  condi- 
tion. He  takes  no  food,  and  his  strength  diminishes 
rapidly,  while  in  mania  the  vegetative  functions  proceed 
rather  favorably.  The  bodily  temperature  of  the  patient 
is  raised  as  high  as  102°  to  103°.  At  times  he  is  quiet, 
apathetic,  almost  stuporous. 

Delirium  acutum  is  usually  lethal.  The  second  week 
of  the  disease  is  the  most  critical  time.  When  the  patient 
has  survived  it  there  is  some  hope  of  recovery. 

The  following  symptom  is  peculiar  to  delirium — 
delirium  acutum.  The  patient  unexpectedly  falls  to  the 
ground,  and  this  evidently  by  intention  (p.  186).  With- 
out trying  to  ward  off  the  fall  by  outstretching  his  hands, 
he  drops  down  in  the  most  unfavorable  manner,  and  then 
he  wallows  and  tries  to  force  his  head  through  carpets 
or  mattresses  the  floor  may  be  covered  with.  All  the 
while  he  is  under  the  influence  of  vivid  hallucinations. 

The  condition  of  the  patient  in  delirium  acutum 
frequently  takes  a  sudden  turn  for  the  better.  The 
consciousness  becomes  entirely  clear,  the  fever  abates,  and 
the  patient  grows  calm  and  takes  nourishment  willingly. 
The  relatives  begin  to  attach  little  value  to  the  physician's 
assertion  that  notwithstanding  the  apparent  improvement 
the  greatest  danger  is  imminent.  And  indeed,  a  day  or 
two  later  the  former  grave  symptoms  reappear,  and  this 
second  attack  leads  to  the  lethal  end. 

At  the  autopsy  great  hypersemia  of  the  brain  is  found 
similar  to  the  cerebral  hypersemia  after  hanging.  The 
view  has,  therefore,  been  advanced  that  delirium  acutum 
is  due  to  venous  hypersemia  of  the  brain  caused  by  some 
toxic  agent.     Acting  upon  this  theory  some  have  made 


SPECIAL  PATHOLOGY  265 

therapeutic  use  of  ergotine  and  maintain  to  have  had 
good  results  with  this  treatment.  The  latter  fact  can  not 
be  denied,  but  the  conclusion  drawn  from  it  is  doubtful. 
For  there  are  conditions  which  resemble  delirium  acutum 
exactly  and  end  in  recovery  without  ergotine  treatment. 
The  question  of  the  beneficial  effect  upon  delirium  acutum 
of  ergotine  would  be  decided  by  the  following  statistical 
proceeding.  Of  all  the  cases  commencing  like  delirium 
acutum  one  should  be  treated  expectatively,  the  next  one 
with  ergotine;  then  again  the  3rd,  5th,  7th,  etc.,  expecta- 
tively, and  the  4th,  6th,  8th,  etc.,  with  ergotine.  The 
comparison  of  the  two  series  will  show  which  treatment 
gives  better  results.  In  such  an  experiment  the  cases  of 
apparent  delirium  acutum  will  be  quite  evenly  distributed 
between  the  two  modes  of  treatment.  But  if  all  cases  are 
treated  with  ergotine,  the  objection  may  be  raised  that 
those  terminating  favorably  have  not  been  cases  of  de- 
lirium acutum,  but  merely  resembled  it. 


Chapter  XCVII. 
TRAUMATIC   INSANITY. 

Traumatic  insanity  is  traceable  to  an  injury,  espe- 
cially of  the  skull.  The  coma  immediately  following  the 
shock  excluded,  the  mental  disorders  of  traumatic  insanity 
appear  in  three  distinct  types. 

One  type  consists  in  violent  hallucinations.  The 
patient  having  recovered  from  the  disturbance  of  con- 
sciousness subsequent  to  the  trauma,  begins  to  hallucinate 
strongly  in  several  senses,  and  this  although  no  bodily 
lesion  of  any  importance  can  be  established.  This  ex- 
citative state  persists  for  weeks,  so  that  serious  symptoms 


266  PSYCHE 

of  exhaustion  arise,  rendering  artificial  feeding  necessary. 
Nevertheless  the  prognosis  is  favorable  if  there  are  no 
signs  of  pareses  and  paralyses.  After  a  few  weeks  con- 
valescence commences  and  is  soon  followed  by  complete 
recovery. 

Of  longer  duration  is  that  form  of  traumatic  insanity 
which  presents  the  clinical  picture  of  paranoia.  Some 
time  after  the  trauma  disturbances  of  the  emotional 
sphere  begin  to  oppress  the  patient  and  become  productive 
of  delusions  of  grievance  and  furtherance  (Ch.  75,  p. 
176).  This  type  of  traumatic  insanity  is  also  of  favor- 
able prognosis  even  in  cases  where  the  paranoia  lasts  for 
a  year  and  longer. 

A  third  form  of  mental  disorder  based  on  trauma 
manifests  itself  by  great  excitability  of  the  central  nervous 
system  associated  with  intolerance  of  alcohol.  The  quan- 
tity of  spirituous  liquors  which  up  to  the  time  of  the 
trauma  the  patient  could  consume  without  the  slightest  ill 
effect,  exerts  now  an  injurious  influence  on  his  nervous 
system.  It  puts  him  into  a  state  of  extraordinary  excite- 
ment, almost  of  frenzy.  The  condition  of  the  patient  is 
such  that  he  may  be  taken  for  an  alcoholic  in  delirium 
tremens.  This  diagnosis  would  not  be  a  matter  of  in- 
difference to  the  patient.  For  the  mental  disorders  based 
on  chronic  alcoholism  are  ultimately  to  be  ascribed  to 
bad  habits  and  wrong  actions,  while  traumatic  insanity 
with  intolerance  of  alcohol  is  not  due  to  any  fault  of  the 
patient's. 

The  degree  of  irritability  of  the  central  nervous  sys- 
tem is  commensurate  with  the  exaggeration  of  the  tendon 
reflexes.  It  is,  therefore,  possible  to  judge  of  the  in- 
creased excitability  of  the  patient  by  the  condition  of  his 
reflexes. 


SPECIAL  PATHOLOGY  267 

Therapy.  Injuries  productive  of  traumatic  insan- 
ity usually  cause  a  concussion  of  the  brain  in  toto  whereby 
its  excitability  becomes  increased  and  its  power  of  resist- 
ance diminished.  For  this  reason  surgical  interference  is, 
as  a  rule,  of  no  avail.  In  some  instances,  however,  it  has 
a  good  effect.  The  skull  is,  therefore,  to  be  examined  for 
depressions  or  fractures,  and  the  lesions  found  are  to  be 
treated  according  to  surgical  principles.  If  no  injury  of 
the  skull  can  be  established,  the  treatment  is  only  symp- 
tomatic. The  patient  must  be  guarded  against  excite- 
ment and  strong  sense  stimuli,  and  the  use  of  alcohol 
and  tobacco  is  to  be  strictly  forbidden. 


Chapter  XCVIII. 
INSANITY  IN  ORGANIC  BRAIN  DISEASES. 

Mental  disorders  are  frequently  due  to  organic  dis- 
eases of  the  brain. 

Huntington's  chorea  is  a  psychosis  consisting  in  a 
slowly  progressing  mental  deterioration  with  pronounced 
dementia  as  the  final  stage.  Besides  choreic  movements 
of  limbs  and  body,  the  patients  present  various  psycho- 
pathic symptoms,  such  as  impairment  of  memory  and 
judgment,  apathy,  irritability,  groundless  outbursts  of 
anger.  At  times  depression  or  mania  is  present.  The 
disease  runs  a  course  of  10  to  30  years.  In  the  terminal 
dementia  the  patients  are  physically  so  weak  that  they 
have  to  be  kept  in  bed.  The  autopsy  reveals  consider- 
able pathological  changes  in  the  meninges  and  cerebral 
cortex. 

Multiple  Sclerosis.  Multiple  sclerosis  is  usually 
associated  with  psychopathic  symptoms.     The  affective 


268  PSYCHE 

state  is  that  of  depression  in  early  stages  of  the  disease. 
Later  sHght  euphoria  prevails.  Occasionally  uncontroll- 
able emotional  outbursts  occur.  The  patients  laugh  or 
weep  without  provocation.  Apathy  is  often  present. 
Memory  and  judgment  are  defective.  The  insight  into 
the  morbidity  of  the  mental  condition  (p.  129)  is  pre- 
served for  a  long  time. 

Apoplexy.  Cerebral  hemorrhages  frequently  lead 
to  an  impairment  of  the  mental  faculties.  In  many  in- 
stances the  patients  become  apathetic.  Their  lack  of 
emotional  control  is  seen  in  outbursts  of  laughing  or 
weeping  without  apparent  cause.  The  power  of  memory 
and  judgment  is  diminished.  The  insight  into  the  dis- 
eased mental  condition  is  wanting  in  some  cases,  but  well 
retained  in  others. 

Brain  Tumor.  Mental  defects  are  met  with  in 
tumors  of  the  brain,  especially  in  large  ones  and  those  of 
the  frontal  lobes.  The  patients  become  indifferent,  for- 
getful, unable  to  endure  any  mental  exertion.  Memory  is 
weakened.  Attacks  of  somnolence  occur  frequently. 
Sometimes  there  is  childish  cheerfulness  with  inclination 
to  joking. 

Cerebral  Syphilis.  The  mental  disorders  due  to 
syphilis  of  the  brain  are  divided  into  two  types,  simple 
syphilitic  dementia  and  syphilitic  pseudoparesis.  The  dif- 
ferentiation of  these  two  types,  however,  is  sometimes 
impossible. 

In  simple  syphilitic  dementia  there  is  an  impairment 
of  memory  and  judgment.  Apoplectiform  and  epilepti- 
form attacks  are  frequent.  The  affective  state  is  often 
exalted.  The  patients  are  subject  to  emotional  outbursts 
and  show  marked  intolerance  of  alcohol.  The  insight 
into  the  disease  is  wanting. 


SPECIAL  PATHOLOGY  269 

Syphilitic  pseudoparesis  usually  begins  with  a  state 
of  depression.  The  patients  become  indifferent  and  for- 
getful. At  times  they  are  very  irritable  and  violent. 
Hallucinations  are  frequent,  especially  in  the  sense  of 
hearing.  Delusions  of  persecution  are  present,  but  they 
are  unstable.  Later  there  is  -exaltation  associated  with 
delusions  of  grandeur.  The  final  stage  is  marked  by  a 
more  or  less  pronounced  dementia,  some  patients  being 
capable  of  useful  occupation,  others  unfit  for  any  work. 
Some  physical  symptoms  contribute  to  render  syphilitic 
insanity  still  more  similar  to  paretic  insanity.  The  pupil- 
lary reaction  is  somewhat  impaired,  and  the  pupils  may 
be  unequal  in  size.  Difference  of  innervation  of  sym- 
metrical parts  and  tremor  in  the  muscles  of  the  face, 
tongue,  and  extremities,  are  noticeable. 

It  is  very  difficult  to  differentiate  syphilitic  insanity 
from  paretic  insanity.  In  the  former  the  memory  is  not 
impaired  to  such  an  extent  as  in  the  latter.  The  char- 
acteristic defective  articulation  of  general  paresis  is  want- 
ing in  syphilitic  insanity. 

Antiluetic  treatment  is  of  little  avail  in  syphilitic  in- 
sanity, yet  it  may  be  tried. 


Chapter  XCIX.  > 

SENILE  INSANITY. 

In  senility  the  vigor  of  mind  shows  a  gradual  pro- 
gressive decline.  Through  the  consuming  effect  of  time 
the  old  memory  images  have  either  faded  away  or  have 
become  so  faint  that  they  can  hardly  be  reproduced.  The 
present    sensations    fail    to    leave    impressions,    do    not 


270  PSYCHE 

''cling, "  in  the  deteriorated  cerebral  elements.  The  asso- 
ciative paths  are  worn  out  by  age,  and  association  is 
hereby  rendered  difficult.  The  power  of  reasoning,  de- 
pending upon  memory  and  association,  is  therefore  im- 
paired. This  mental  enfeeblement  of  old  age,  called 
dotage,  is  to  be  considered  physiological,  since  it  is 
founded  on  the  natural  deterioration  of  the  brain  through 
senescence.  There  is,  however,  in  advanced  age  an  im- 
pairment of  the  mental  faculties  which  is  due  to  patho- 
logical factors  and  may  therefore  be  designated  as  senile 
insanity. 

Senile  insanity  is  founded  on  an  exaggeration  of  the 
brain's  senescence  in  the  general  senile  alteration  of  all 
organs.  It  appears  under  the  clinical  pictures  of  melan- 
cholia and  mania  followed  by  dementia.  Some  patients 
show  all  these  three  forms  of  mental  disorder,  one  after 
the  other,  in  other  patients  the  melancholia  or  the  mania 
is  missing.  The  succession  of  the  clinical  pictures  of 
senile  insanity  is,  therefore,  as  follows:  (i)  Melan- 
cholia— Dementia;  (2)  Mania — Dementia;  (3)  Melan- 
cholia— Mania — Dementia.  In  some  instances  senile  in- 
sanity has  the  periodic  character,  melancholic  or  maniacal 
excitement  alternating  with  intervals  of  well-being. 

The  melancholia  of  senile  insanity  has  some  charac- 
teristic traits.  The  patients  are  troubled  with  groundless 
cares  of  sustenance.  Although  possessed  of  wealth,  they 
complain  about  dire  poverty  and  assert  that  they  have  to 
deny  themselves  everything  in  order  to  save  for  their 
children.  We  would  be  inclined  to  regard  such  patients 
as  old  misers.  But  when  we  see  that  their  sleep  is  dis- 
turbed, their  nutritive  state  greatly  reduced,  and  their 
strength  gradually  waning,  we  will  recognize  that  it  is  not 
niggardliness  which  causes  the  patients'   worries  about 


SPECIAL  PATHOLOGY  271 

their  own  subsistence  and  that  of  their  dear  ones.  These 
cares  about  sustenance  may  drive  the  patients  to  suicide. 
Many  a  case  of  suicide  at  an  advanced  age  is  to  be  attrib- 
uted to  senile  melancholia. 

Senile  mania  also  shows  some  peculiarities.  The 
senile  maniac  feels  young  again.  He  boasts  that  in  spite 
of  his  70  years  he  can  accomplish  as  much  as  a  man  of 
30.  He  dresses  like  a  young  man,  after  the  newest 
fashion,  carries  a  walking  cane  in  his  hand  and  a  cigar  in 
his  mouth,  and  in  this  attire  he  flaunts  about  the  streets. 
Confidentially  he  betrays  to  a  companion  that  his  virile 
potency  is  excellent.  This  last  point  must  be  borne  in 
mind  for  the  reason  that  senile  maniacs  frequently  come 
into  conflict  with  the  Penal  Code  in  consequence  of  sexual 
overexcitement.  Driven  by  their  morbid  sexual  desires 
they  importune  not  only  other  people's  children,  but  even 
render  themselves  guilty  of  illicit  relations  with  their  own 
grandchildren.  People  sometimes  speak  of  an  old  liber- 
tine who  had  to  go  to  the  penitentiary  for  rape.  But  the 
physician  cognizant  of  the  fact  that  sexual  excitement 
belongs  to  the  symptoms  of  senile  mania,  will,  in  a  given 
case,  investigate  the  matter  somewhat  closer.  He  will 
try  to  find  out  whether  the  defendant  has  manifested  other 
indications  of  mental  disease,  and  having  established  this, 
will  plead  for  his  acquittal  on  the  ground  of  insanity. 

A  serious  feature  of  senile  insanity  is  the  unexpected 
occurrence  of  fatal  apoplexies.  This  will  not  appear  ex- 
traordinary when  we  consider  that  the  senescence  of  the 
brain,  which  is  the  chief  etiological  factor  of  senile  in- 
sanity, is  founded  on  atheromatosis  of  the  cerebral  blood 
vessels,  and  this  pathologic-anatomic  alteration  is  also  the 
cause  of  cerebral  hemorrhages.  The  relatives  of  the 
patient  must  be  warned  that  fatal  termination  through 


272  PSYCHE 

apoplexy  occurs  unexpectedly  in  senile  insanity.  If  their 
attention  has  not  been  called  in  time  to  this  eventuality, 
they  are  distrustful  when  a  misfortune  happens  suddenly, 
and  suspect  that  their  patient  has  been  ill  treated  or 
neglected,  and  it  may  become  necessary  to  prove  by 
autopsy  the  cause  of  his  precipitate  death. 

Prognosis.  During  the  melancholic  or  maniacal  ex- 
citement death  may  result  from  exhaustion.  The  refusal 
of  food  in  senile  melancholia  is  much  more  fraught  with 
danger  than  in  insanity  of  young  patients.  Sudden  apo- 
plexies may  speedily  end  the  patients'  lives.  When  how- 
ever the  acute  stages  of  senile  insanity  have  passed  off 
without  fatal  termination,  the  patients  enter  into  the  more 
permanent  stage  of  dementia.  Their  condition  is  then 
less  changeable,  their  conduct  less  dangerous  than  for- 
merly, and  they  are,  therefore,  fit  for  private  care. 


ERRATA 

Page     19,  line  9  from  below,  read :  14-16  instead  of  14-15. 

Page    20,  line  4  from  above,  read :  it  is  instead  of  'is.' 

Page    48,  line  10  from  below,  read:  comma  (,)  after  *on.' 

Page     74,  line  6  from  below,  read:  period  (.)  instead  of  colon  (:). 

Page    74,  lines  3  and  5  from  below,  read :  House  instead  of  house. 

Page    80,  first  line,  read:  comma  (,)  after  'impulse.' 

Page    92,  line  6  from  below,  read:  period  (.)  instead  of  colon  (:). 

Page  106,  last  line,  read :  numbers  instead  of  number. 

Page  155,  line  16  from  above,  read:  comma   (,)   after  'day.' 

Page  167,  line  14  from  above,  read:  comma  (,)  after  'tractability.* 

Page  177,  line  14  from  below,  read:  semicolon  (  ;)  instead  of  colon  (  :). 

Page  218,  line  12  from  below,  read:  comma  (,)  after  'system.' 

Page  254,  line  8  from  below,  read:  into  instead  of  in. 

Page  264,  line  11  from  above,  read:  comma  (,)  after  'it.' 

Page  278,  line  9  from  below,  read:  119  after  '115.' 


INDEX 


Aboulia,  jy^  222. 
Abstinence,  123,  175,  258,  259. 
Acoustic  nerve,  7. 
Activity,  234. 
Adolescence,  153,  224. 
Affective   sphere,   36,    160,   181, 

197,  199,  204,  224. 
Affective    state,    14,    17-18;    in 

hallucinatory  insanity,  170;  in 

paranoia,  176. 
Affective  tones,  13 ;  physiologic- 
anatomic  explanation  of,  14; 

a.  t.  in  compulsory  ideas,  72; 

in  idiocy,   197,  201,  204,  208. 
Age  and  psychoses,  153. 
Agoraphobia,  39,  71. 
Agricultural    system   of    insane 

asylums,  139. 
Akinetic  stereotypy,  80. 
Alcohol,  7,   108,   116,    194,  233, 

257,  267. 
Alcoholic  beverages,  116,  257. 
Alcoholic  insanity,  257. 
Alcoholism,  chronic,  117,  257. 
Alienation,  103. 
Alternating  insanity,  236. 
Amnesia,  60,  64,  65,  246. 
Anaesthesia  of  the  skin,  98. 
Anaesthesia,  general,  to  subdue 

an  unmanageable  patient,  136. 
Analysis,  21. 
Angry    mood,    in    hallucinatory 

insanity,  170;  in  mania,  163, 

166. 
Antiluetic  treatment,  value  of  a. 

t.  in  paretic  insanity,  254;  in 

syphilitic  insanity,  269. 
Anxiety,    a    cause    of    insanity, 

113;     emotional     attacks     of 

anxiety,  33,  34,  154,  158. 


Aphasia,  65. 

Apathy,  189,  225,  267,  268. 

Apoplectiform  attacks,  93,  227- 

248,  251,  255. 
Apoplexy,  268,  271. 
Apperception,  21. 
Appetite,  156,  167,  170,  182. 
Argyle-Robertson  pupil,  97. 
Arsenic  poisoning,  118. 
Arson,  199,  202. 
Articulation,     faulty,    97,     127, 

250. 
Assimilation,  156,  158,  167,  170, 

182. 
Association,    8,    19-20;    facility 

of,  73;  difficulty  of,  74;  fibres 

of  association,  8,  15,  23. 
Asymetry  of  the  skull,  iii,  197, 

199,  216. 
Astraphobia,  71. 
Asylum,  137. 
Atheromatosis,  271. 
Attention,  21 ;  monopolizing  of 

the  a.  by  hallucinations,  52. 
Atropine,  94,  118. 
Auditory  hallucinations,  46;  in 

paranoia,  177. 
Aura    of    the    epileptic    attack, 

243- 
Automatism,  7,  79,  90,  229;  of 
command,   82,    91 ;   of   imita- 
tion, 82,  226. 

Barrenness     of     the     affective 

sphere,  36,  160,  189,  224. 
Baths,  158,  188. 
Beer,  117,  257. 
Bladder,   disorders  of,  97,   159, 

254- 
Blind,  mentally,  11. 


274 


INDEX 


Blindness,  visual  hallucinations 
in,  45. 

Blood,  its  importance  for  the 
brain,  5,  17;  loss  of  b.,  a  cause 
of  insanity,  156,  160,  192. 

Brandy,  117,  257. 

Cachexia  strumipriva,  216. 

Canities,  96,  156. 

Care  of  sustenance,  a  cause  of 
insanity,  113. 

Carotid  arteries,  compression 
of,  5,  ^y. 

Catalepsy,  82,  230. 

Catatonia,  230. 

Cerebro-spinal  fluid,  16,  196. 

Changeling,  215. 

Character,  alteration  of  charac- 
ter in  paretic  insanity,  247; 
alcoholic  depravity  of  charac- 
ter, 257. 

Child,  overburdening  of  the  c, 
a  cause  of  insanity,  114. 

Chloral  hydrate,   118,   144,   188. 

Cholera,  115. 

Chorea,  Huntington's,  267. 

Circular  insanity,  127,  163,  233, 
236. 

Circulation,  sluggish  blood  cir- 
culation, 156,  191. 

Civilization,  104. 

Claustrophobia,  71. 

Climacterium,  153,  240. 

Closed  institutions,  139. 

Clubfoot,  112. 

Cocaine,  94,  113,  118. 

Colobomata,  112. 

Comparisons,  in  the  activity  of 
the  understanding,  21. 

Composite  feeling,  14. 

Compulsion,  mechanical,  in  the 
treatment  of  the  insane,  140. 

Compulsory  actions,  86. 

Compulsory  ideas,  39,  68,  72. 

Concussion  of  the  brain,  267. 

Confounding  of  persons,  68, 
185. 


Confusion,  52,  173,  184,  185. 

Consciousness,  27;  c.  and  mem- 
ory, 65;  c.  and  sleep,  90;  dis- 
turbance of,  65,  90,  93,  160, 
185,  187,  227,  230. 

Constriction  of  the  nasal  root, 
216. 

Contact,  fear  of,  70. 

Contrary  sexual  feeling,  212. 

Convalescence,  72,  96,  128. 

Convolution,  frontal,  203. 

Coprolalia,  39. 

Coprophagia,  38,  39. 

Corpus  callosum,  203. 

Corti,  organ  of,  7. 

Cretinism,  196,  214. 

Crime,  family  history  of,  108; 
punishment  for,  76 ;  source  of, 
56,  175. 

Critique,  "want  of  c,"  74. 

Crying,  instinct  of,  26. 

Cryptorchismus,  208. 

Cyanosis,  156,  228,  243. 

Cystitis,  254. 

Deaf,  psychically,  11. 

Death,  a  termination  of  psy- 
choses,  131. 

Death  of  a  near  relative,  a 
cause  of  insanity,  113. 

Deduction,  21. 

Decubitus,  98. 

Deglutition,  impairment  of,  145, 

254. 

Dejection,  31,  234. 

Delirium,  185 ;  differentiated 
from  melancholia,  157;  from 
mania  and  hallucinatory  in- 
sanity, 187;  deliria  of  absti- 
nence, 123,  259 ;  in  drug  pois- 
oning, 118;  in  infectious  dis- 
eases, 115;  d.  marked  by 
numerous  hallucinations,  51 ; 
by  abrupt  onset  and  rapid 
course,  123,  125. 

Delirium  acutum,  123,  263. 

Delirium  tremens,  123,  259. 


INDEX 


275 


Delusions,  definition  and  source 
of,  34,  36,  52,  53-54;  classifi- 
cation and  diagnostic  value 
of>  55-56;  d.  in  alcoholic  in- 
sanity, 260;  d.  productive  of 
morbid  impulses,  89; — of  in- 
crease of  energy,  85 ; — of  per- 
verse acts,  39; — of  refusal  of 
food,  96,  144;  effect  of  hyp- 
notism on  d.,  147. 

Dementia,  i)  primary  curable, 
192;  differentiated  from  mel- 
ancholia, 156;  from  secondary 
dementia,  193;  from  stupor, 
160;  2)  secondary,  189;  form- 
ing final  stage  of  psychoses, 
130,  169;  differentiated  from 
stupor,  160;  nutritive  distur- 
bances in  d.,  96,  191 ;  reduc- 
tion of  energy  in  d.,  84 ;  para- 
lytic d.,  249;  senile  d.,  270; 
simple  syphilitic  d.,  268. 

Dementia  praecox,  56,  153,  224; 
— paranoides,  230. 

Depression,  cardinal  symptom 
of  melancholia,  154-156,  159, 
163,  233;  criteria  for  morbid 
d.,  31 ;  its  influence  on  the 
psychical  functions,  33;  treat- 
ment, 141,  147;  d.  in  hallu- 
cinatory insanity,  170;  in  de- 
mentia praecox,  229. 

Depressive  excitement,  237. 

Derailment  of  the  will,  81. 

Dermography,  228. 

Destructiveness,    140,    143,   230. 

Devilry,  48,  50,  51,  179,  215. 

Digestion,  156,  158,  167,  170, 
182. 

Diphtheritic  paralyses,  115. 

Disorientation,  94,  185. 

Disputatiousness,  209. 

Doggerel,  226. 

Dotage,  270. 

Double  consciousness,  92. 

Doubting  habit,  70. 

Doute,  folie  du  doute,  70. 


Drunkenness,  108. 

Duration  of  the  psychoses,  125. 

Dwarfishness,  196,  216. 

Ear,  fautly  development  of,  iii. 

Eccentricity,  108,  224. 

Echolalia,  82,  226. 

Echopraxia,  82,  2.26. 

Ecstasy,  159. 

Educability,  "want  of  e.,"  205. 

Emotion,  14;  emotions  in  idiocy, 
n,  197,  200. 

Egotism,  220. 

Energy,  83;  decrease  of,  36,  84, 
154,  156;  increase  of,  36,  83, 
85,  156,  157,  166,  176,  182. 

Equilibrium  of  the  body,  97. 

Epilepsy,  120,  242-246;  in  al- 
coholics, 260;  in  idocy,  197; 
family  history  of,  108;  per- 
verse feelings  in  e.,  38 ;  deliria 
in  e.,  186;  short  psychoses  in 
e.,  126;  states  of  clouded  con- 
sciousness in  e.,  66,  92;  epil- 
epsy differentiated  from  mel- 
ancholia,  157. 

Epileptic  attack,  243. 

Epileptic  insanity,  242,  259,  260. 

Epileptiform  attacks,  93,  227, 
251,  255. 

Ergotine,  265. 

Ethical  conceptions  in  idiocy, 
197,  204. 

Euphoria,  268. 

Exaltation,  cardinal  symptom  of 
mania,  162,  163,  234;  criteria 
for  morbid  e.,  34-35;  its  in- 
fluence on  the  psychical  func- 
tions, 35-36 ;  treatment,  141 ; 
e.  in  hallucinatory  insanity, 
170. 

Exciting  causes  of  insanity,  103. 

Exercises,  143,  158,  161. 

Exertion,  a  cause  of  insanity, 
113. 

Falling  down,  intentional,  186, 
264. 


276 


INDEX 


Family  history  of  insanity,  107, 
108. 

Feeble-mindedness,  epileptic, 
242;  secondary,  133,  169,  189. 

Feeding,  artificial,  144,  157,  161, 
181,  254,  255. 

Feeling,  13;  physiologic-ana- 
tomic explanation  of,  14. 

Fever,  115,  157,  185,  264. 

Fickleness,  112,  201. 

Fire,  predilection  for,  199. 

Fixed  delusions,  59,  130,  182. 

Flexibilitas  cerea,  82,  160. 

Flight  of  ideas,  36,  42,  74,  86, 
164,  234. 

Forensic  consideration,  in  alco- 
holic insanity,  261 ; — compul- 
sory ideas,  87 ; — dementia 
praecox,  229;  in  determining 
the  beginning  of  a  psychosis, 
125;  in  epilepsy,  66,  244,  246; 
— imbecility,  63,  202,  203; — 
mania  transitoria,  126; — mor- 
bid mood,  33; — paranoia,  180; 
— paretic  insanity,  248,  255- 
256;  in  psychoses  caused  by 
imprisonment,  1 14 ; — querul- 
ous insanity,  209-210; — secon- 
dary insanity,  184; — senile  in- 
sanity, 271 ; — sexual  perversi- 
ty, 212,  214;  in  want  of  free- 
dom of  the  will,  25,  56,  '^6] 
see  also  crime,  malingery, 
Penal  Code. 

Forgery,  255. 

Freedom  of  the  will,  25,  56,  y6. 

Fright,  a  cause  of  insanity,  113. 

Furtherance,  delusions  of,  55, 
57,  176,  179. 

Fusel  oil,  117. 

Gait,  defective,  97. 

Gangrene,  98,  135,  188. 

Gaps    of    memory,    in    epilepsy, 

66,  93;  in  hysteria,  6y. 
"Gedankenarme  Manie,"  237. 


"Gedankenreiche    Melancholia," 

239- 

General  paresis,  246-256;  ab- 
surd delusions  in,  56;  age, 
153,  247;  anaesthesia,  99; 
Argyle-Robertson  pupil,  97 ; 
apoplectiform  and  epilepti- 
form attacks,  93,  227;  early 
intellectual  enfeeblement,  232 ; 
frequency  in  civilized  lands, 
105;  handwriting,  166;  in- 
crease of  energy,  84;  impair- 
ment of  memory,  64,  65;  of 
understanding,  75 ;  klepto- 
mania in,  89,  168;  long  pre- 
cursory stage,  123;  prognosis, 
131,  134,  253;  remissions, 
127,  251 ;  differentiation  from 
dementia  praecox,  232;  from 
recurrent  insanity,  241 ; — sy- 
philitic insanity,  269. 

Genius,  108. 

Giftedness,  family  history  of, 
108. 

Goitre,  196,  202,  216,  228. 

Grandeur,  delusions  of,  55-57, 
142,  165,  166,  179. 

Grievance,  delusions  of,  55,  56, 
156,  173,  176,  179. 

Grimacing,  237. 

"Griibelsucht,"  70. 

Hair,  graying  of,  96,  156. 

Hallucinations,  42-46;  sequelae 
and  symptoms  of,  51 ;  audi- 
tory h.,  45,  46;  gustatory,  ol- 
factory, and  tactile  h.,  50; 
visual  h.,  45,  49. 

Hallucinatory  idea,  image,  11, 
44. 

Hallucinatory  insanity,  170,  260, 
265;  differentiated  from  me- 
lancholia, 157;  from  delirium, 
187. 

Handwriting,  127,  166. 

Hanging,  disturbance  of  mem- 
ory after,  6y;  hyperaemia  of 


INDEX 


^17 


the  brain  after,  264;  suicide 
through,  145. 

Heart,  disturbance  of  the  activ- 
ity of,  99. 

Hebephrenia,  228. 

"Heitere  Verstimmung,"  234. 

Hemiplegia  in  idiocy,  196. 

Hepatitis,  257. 

Heredity,  107. 

Hereditary  insanity,  168,  218. 

Hereditary  predisposition  to  in- 
sanity, 107,  108,  no,  112,  218. 

Hernia,  congenital,  112. 

Homicidal  mania,  88,  230. 

Homicide,  marked  by  brutality, 
244,  245. 

Homosexuality,  40. 

Honor,  violation  of  h.,  a  cause 
of  insanity,  113. 

Hydrocephalus,  196. 

Hyperaemia  of  the  brain,  264. 

Hypermetropia,   excessive,    112. 

Hypermnesia,  60,  63,  74,  200. 

Hypersuggestibility,  82,  226. 

Hypnotics,  117,  144. 

Hypnotism,  91 ;  a  therapeutic 
measure,  147. 

Hypoboulia,  78. 

Hypochondria,  96,  222,  228,  229. 

Hypospadia,  112. 

Hysteria,  anaesthesia  in,  99; 
disturbance  of  consciousness, 
93;  family  history  of,  107- 
108;  psychoses  of  short  dura- 
tion in,  126. 

Hysterical  insanity,  219. 

Idea,  9;  course  or  train  of 
ideas,  13;  dominant  idea,  159, 
160. 

Ideational  process,  13,  41 ;  in- 
fluence of  the  affective  state 
upon,  18-20;  acceleration  of, 
35,  36,  42,  165 ;  retardation  of, 
33,  41,  155;  in  hallucinatory 
insanity,  170;  in  stupor,  159. 


Ideational  sphere,  impairment 
of,  130;  in  paranoia,  176. 

Idiocy,  195;  barrenness  of  the 
affective  sphere  in,  36;  de- 
crease and  increase  of  energy 
in,  85,  86;  increased  capacity 
of  memory  in,  62,  63 ; — of  un- 
derstanding, 74;  irritable  af- 
fective state  in,  38;  perverse 
feelings  in,  38;  inferior  idi- 
ocy, 197;  superior  idiocy,  199. 

Idiomuscular  swelling,  228. 

Illusion,  42-44,  53,  60,  154,  155, 

243- 

Imagination,  21. 

Imbecility,  196,  199. 

Imitation,  instinct  of,  27. 

Immobility  of  thought,  234. 

Imperative  action,  86. 

Imperative  idea,  see  compul- 
sory. 

Imperative  impulse,  86. 

Impotence,  virile,  40. 

Impression,  7-8;  failure  of  sen- 
sations to  leave  impressions, 
64,  65,  269 ;  destruction  of  im- 
pressions, 65. 

Impulse,  natural,  see  instinct. 

"Impulse  action,"  26. 

Imprisonment,  a  cause  of  in- 
sanity, 114,  117. 

Inactivity,  234. 

Indeterminism,  25. 

Induction,  21. 

Infectious  diseases,  115,  116, 
156,  160,  162,  186. 

Infinitives,  mode  of  speech  of 
idiots,  198. 

Initial  symptoms  of  psychoses, 
mistaken  for  their  cause,  124. 

Insanity,  definition,  103, 

Insight  into  the  disease,  128- 
129,  223,  268. 

Insolation,  162. 

Insomnia,  6,  118,  144. 

Instinct,  26. 


278 


INDEX 


Institutional  treatment  of  the 
sane,  common  reluctance  to, 
132. 

Interference,  81. 

Intermarriage,  106. 

Interval,  free  interval  of  period- 
ic insanity,  126,  129. 

Intolerance  of  alcohol,  261,  266, 
268. 

Intoxication,  154,  157,  175;  al- 
cohol intoxication,  117,  257. 

Intuition,  12. 

Iodoform  poisoning,  118. 

Irascibility,  200. 

Irritability  of  the  brain,  5. 

Isolation,  symptoms  of  isola- 
tion, 166. 

Jaw,  deformity  of,  iii. 
Jealousy,  alcoholic  delusions  of, 

260. 
Jews,     frequency     of     insanity 

among  J.,  106-107. 
Judgment,  21. 

Kinetic  stereotypy,  80. 
Kleptomania,  88,  168. 

Lactation,  219,  240, 

Lead  poisoning,  118. 

Legal  matters,  see  forensic  con- 
sideration. 

Liquor  cerebro-spinalis,  16. 

Litigiousness,  209. 

Love,  rejected  1.,  a  cause  of  in- 
sanity, 113. 

Lucid  interval,  240. 

Lues,  115,  268. 

Macrocephalia,  196. 

Malingery,  33,  39,  53,  87,  126, 
143,  167,  246. 

Mannerism,  80,  226,  239. 

Mania,  162-169;  in  paretic  in- 
sanity, 249; — recurrent  insan- 
ity, 235-236,  241 ; — senile  in- 
sanity,     271 ;      differentiated 


from  delirium,  187,  263; — 
hallucinatory  insanity,  173 ; 
paranoia,  180. 

Manic,  maniacal,  definition,  162. 

Maniacal  affective  state,  35. 

Maniacal  excitement,  delusions 
of  grandeur  in,  55;  improve- 
ment of  memory,  61 ;  of  un- 
derstanding, 73;  increase  of 
energy  in,  83;  increased  vo- 
litional activity,  78. 

Manic-depressive   insanity,   163, 

233- 

Massage,  143,  158,  161. 

Melancholia,  154-158;  m.  agita- 
ta, 155,  238;  in  paretic  in- 
sanity, 249-250  ; — recurrent  in- 
sanity, 235-236,  241 ;  in  senile 
insanity,  270;  differentiated 
from  hallucinatory  insanity, 
174; — paranoia,  180;  dimin- 
ished frequency  of  volitional 
manifestations  in  m.,  78;  di- 
minution of  energy,  84;  re- 
fusal of  food,  143. 

Melancholic  affective  state,  33. 

Melancholic  excitement,  221. 

Medullated  nerve  fibres,  8. 

Memory,  11;  disturbance  of  m., 
60,  ^y ;  diminished  capacity  of 
m.,  64-67;  abnormally  in- 
creased capacity  of  m.,  61-63; 
m.  in  dementia  praecox,  225; 
— hallucinatory  insanity,  170; 
— idiocy,  199,  200 ; — mania, 
42,  61,  163;  melancholia,  154; 
— Huntington's  chorea,  267 ; 
— multiple  sclerosis,  268. 

Memory  image,  9,  20. 

Meningitis,   196. 

Menstruation,  240. 

Mental  overexertion,  a  cause  of 
insanity,  113. 

Mercury  poisoning,  118. 

Metabolism  of  the  brain,  5. 

Microcephalia,  196,  202. 


INDEX 


279 


Mind,   I. 

Mixed  states  in  manic-depres- 
sive insanity,  163,  237. 

Mobility  of  thought,  234. 

Modernized  delusions^  179. 

Monomania,  89,  167. 

Mood,  14;  treatment  of  morbid 
m.,  141. 

Moral  idiocy,  moral  insanity, 
196,  204. 

Morphinism,  118,  123. 

Motor  disturbances  in  the  in- 
sane, 97. 

Motor  image,  impression,  8. 

Motor  sensation,  7. 

Murder,  156,  180. 

Muscular  irritability,  increase 
of,  228. 

Muscular  power,  abuse  of,  84. 

Mutism,  83,  229. 

Mysophobia,  71. 

Myxoedema,  216. 


Nagging  mania,  237. 

Nails,  nutritive  disturbance  of, 

96. 

Nanism,  216. 

Negativism,  82,  226,  229. 

Nephritis,  257. 

Neurasthenia,  222;  family  his- 
tory of,  107,  108. 

Neurology,  i. 

Neuropathology,  i. 

New-born,  movements  of,  22. 

Nicotine  poisoning,  249. 

Non-freedom  of  the  will,  25,  56, 
76,  212. 

"Norgelnde  Manie,"  237. 

Nutritive  state  of  the  brain,  16, 

Nymphomania,  88,   168. 


Oblique  posture  of  the  body,  97. 
Obliquity  of  the  skull,  ill,  196. 
Occipital  lobe,  7. 
Oedema,   156,  158,  161,  228. 


Oesophagus,    foreign    body    in, 

146;  lesion  of,  146. 
Onset  of  the  osychoses,  123. 
Optic  nerve,  7. 
Opium,  118. 

Orientation,  28,  160,  185,  238. 
Originary  insanity,  211. 

Pachymeningitis  haemorrhagi- 
ca,  95. 

Paraldehyde,  145. 

Paralogia,  83,  227. 

Paralytic  attacks,  251. 

Paranoia,  176-181 ;  in  alcoholic 
insanity,  261 ; — hysterical  in- 
sanity, 221 ;  traumatic  insan- 
ity, 266;  delusions  in  p.,  56, 
58,  74;  p.  differentiated  from 
hallucinatory  insanity,  173; — 
melancholia,  156; — originary 
insanity,  211;  increase  of  en- 
ergy in  p.,  85;  periodic  p., 
128;   want  of  critique  in  p., 

74- 

Paresis,  a  disturbance  of  the 
bodily  equilibrium,  97;  pa- 
reses  in  idiots,  196. 

Paretic  insanity,  246,  269;  see 
general  paresis. 

Pavilion  system  of  insane  asyl- 
ums, 139. 

Pederasty,  40,  212-213. 

Pellagra,  118. 

Penal  Code,  conflict  of  insane 
patients  with,  68,  180,  184, 
202,  212,  221,  245,  261,  271 ; 
see   forensic    consideration. 

Perceiving,  modes  of,   12. 

Perception,  11. 

Periodic  insanity,  126,  128,  163, 
168,  233;  periodic  mania,  236, 
270; — melancholia,  236,  270; 
— paranoia,  128,  181. 

Perjury,  255. 

Persecution,  delusions  of,  155, 
179,  229. 

Perspiration,  186,  228. 


28o 


INDEX 


Perturbations,  physiological,  218, 
219,  239,  240. 

Perverse  feeling,  38. 

Perverse  sexuality,  40,  212. 

Phantasy,  12. 

Phlegmon,  146,  188,  254. 

Phobias,  70,  71,  222. 

Phonomania,  88,  168. 

Phrenasthenia,  222^  232,  242. 

Physiological  latitude,  45. 

Pneumonia,  aspiration  pn.,  254. 

Poison,  fear  of,  51,  144. 

Poisons  in  the  etiology  of  in- 
sanity, 116. 

Porencephalia,   197. 

Postepileptic  insanity,  243,  244. 

Precordial  anxiety,  34. 

Predisposing  causes  of  insanity, 
103. 

Predisposition  to  insanity,  63, 
107-110. 

Preepileptic   insanity,   243,   244. 

Pregnancy,  39,  219,  240. 

Prognathism,  iii,  216. 

Pseudoparesis  syphilitica,  268- 
269. 

Psychasthenia,  73,  'jy,  222. 

Psyche,  i. 

Psychic,  psychical,  definition,  i. 

Psychic  equivalents  of  the  epil- 
eptic attacks,  dd,  92,  120,  126, 
157,  186,  242-245. 

Psychical  influences  in  the  eti- 
ology of  insanity,  113. 

Psychiatry,  i. 

Psychology,  i. 

Psychomotor  inhibition,  238. 

Psychosis,  103;  classification  of 
the  psychoses,  151. 

Puberty,  153,  218,  224. 

Puerperium,  219,  240. 

Punishment,  in  non-freedom  of 
the  will,  'jd',  of  embecile  chil- 
dren, 201. 

Pupillary  reaction,  97,  127,  248, 
256,  269. 


Pyelonephritis,  98. 
Pyromania,  88,  168,  199. 

Querulous  insanity,  209. 

Rabies,  fear  of,  71. 

Ragamuffins  suffering  from  de- 
mentia praecox,  229. 

Raptus  melancholicus,  221. 

"Rat's  ear,"  iii. 

Reason,  21. 

Reasoning,  21. 

Recurrent  insanity,  126,  128, 
^53'  163,  219,  233;  recurrent 
mania,  236;  —  melancholia, 
236; — paranoia,    128,    181. 

Reflex    movements,    7,    22,    78, 

159,  160. 
Reflex  arc,  22. 

Refusal  of  food,  in  delirium, 
1 86 ; — dementia,  96 ; — halluci- 
natory insanity,  170,  172,  173; 
— hypochondria,  96 ; — hysteri- 
cal insanity,  220;  melancho- 
lia, 96,  143,  157,  272; — para- 
noia, 85,  96,  143; — stupor,  96, 
143;  danger  of  r.  o.  f.  in 
senile  insanity,  272;  treat- 
ment, 138,  143-144,  147. 

Regurgitation  of  food,  146. 

Relations  in  the  activity  of  the 
understanding,  21. 

Religion,  in  the  etiology  of  in- 
sanity, 106. 

Religious  insanity,  178;  r.  para- 
noia,  179,   180. 

Remissions,   127,  251. 

Responsibility  of  the  family 
physician,  132-133. 

Resistance  in  the  nervous  ele- 
ments, 19-20. 

Rest  cure,  158. 

Retina,  7. 

Retiring  disposition,  112. 

Regidity   of   the   muscles,    159, 

160,  230. 
Rigor  mortis,  146. 


INDEX 


281 


Scarlatina,  115. 
Sclererosis,  multiple,  167. 
Secale  cornutum,  118. 
Secondary  insanity,  59,  181. 
Secretiveness,  112. 
"Seelenblind,"  11. 
"Seelentaub,"  11. 
Self-consciousness,    27,    28,    94, 

198. 
Self-depreciation,    delusions    of, 

55-58,  155-158. 
Self-mutilation,  85,  180. 
Self-preservation,     instinct     of, 

27,  88. 
Semi-consciousness,  90,  92,  244. 
Senescence,  270. 
Senile  insanity,  169,  247,  269. 
Sensation,    7;    pure    sensation, 

II. 
"Sensation  cells,"  8. 
"Sensation  fibres,"  8. 
Sense  feeling,  13. 
Sense  impressions,  7. 
Senses,  6,  7. 

Sensibility,  disturbance  of,  98. 
Sensory  image,  7. 
Sensory  elements,  8. 
Serodiagnostic  investigation,  1 16. 
Sexual    excitement,     168,    220, 

271. 
Sexual  perversity,  40,  212. 
Shock,  a  cause  of  insanity,  113. 
Sitophobia,  96. 
Skin,    anaesthesia    of,    98,    99; 

cyanosis    of,    156;    fatty   and 

oedematous    degeneration    of, 

216;    impaired   nutrition,   96; 

lesions  of,  147,  255. 
Skull,    deformity   of,    iii,    196, 

199,  216. 
Slavering,  159. 
Sleep,  6,  90,  95,  156,  161,  176, 

182,  223. 
Sleeplessness,  see  insomnia. 
Smiling,  instinct  of,  26. 
"Snouting  cramp,"  80. 


Somatic  disturbances  in  the  in- 
sane, 95. 
Somnambulism,  90. 
Somnolence,  95,  268. 
Speech,  faculty  of  s.  in  idiots, 

195,  197,  199. 

Spirituous  liquors,  116. 

Stereotypy,  79,  80,  226,  229. 

Stigmata  of  hereditary  predis- 
position to  insanity,  no. 

Stimulants,  for  facilitating  the 
association,  73;  habitual,  113, 
117,  259. 

Strain,  mental,  a  cause  of  in- 
sanity, 113. 

Straight-jacket,   135. 

Strangulation,  145. 

Stupor,  37,  78,  84,  96,  159,  162, 
228-231,  264. 

Sucking,  instinct  of,  26. 

Suggestion,  146. 

Suicide,  dy,  96,  105,  133,  138, 
145,  156,  157,  258,  261,  271; 
family  history  of,  108. 

Sulfonal,  145. 

Surprise,  joyful,  a  cause  of  in- 
sanity, 113. 

Synchondrosis,   216. 

Synthesis,  21. 

Syphilis,  115,  268. 

Syphilitic  dementia,  simple,  268. 

Systematized  delusions,  58,  174, 
178,  211. 

Tabes,  97,   115,  249. 

"Tardy"  pulse  curve,  99. 

Temperature,  decrease  of,  156; 
increase,  115,  185,  264. 

Temporal  lobe,  7. 

Tension  in  the  nervous  ele- 
ments, 19,  20. 

Termination  of  the  psychoses, 
128. 

Theft,  88,  255. 

Thyroid  gland,  202,  216,  217. 

Tics,  79,  225. 

Tobacco,  73,  113,  233,  267. 


282 


INDEX 


Tongue,   faulty   innervation  of, 

97. 
Toxic  insanity,  153,  257. 
Toxines,  115,  116,  186. 
Tractability  of  the  maniacs,  86, 

142,  167,  169. 
Transport  of  insane  patients  to 

the  asylum,  134. 
Trauma,  118,  175. 
Traumatic  epilepsy,  93. 
Traumatic  insanity,  265. 
Traumatic  psychoses,   119,   153. 
Traumatism,  103. 
"Traurige   Verstimmung,"    233. 
Tremor,  228,  269. 
Trophoneurotic  disturbances,  98. 
Tumor  of  the  brain,  268. 
Typhoid  Fever,  103,  115. 

Understanding,  20,  73,  276. 


Vagabonds  suffering  from  de- 
mentia praecox,  229. 

Vasomotor  center,  16. 

Vasomotor  disturbances,  228. 

Vegetative  processes,  in  hallu- 
cinatory insanity,  170; — ma- 
nia, 163,  167; — melancholia, 
156 ; — paranoia,      1 76 ;  —  sec- 


ondary dementia,  191 ;  stupor, 
160. 

Venous  system  of  the  brain,  15. 

Verbigeration,  80,  226. 

Vertebral  arteries,  5. 

Vertebral  canal,  16. 

Visual  hallucinations,  49 ; — of 
the  alcoholics,  260. 

Volitional  action,  simple,  26. 

Volitional  manifestations,  de- 
crease of  the  frequency  of, 
77-79,  155,  159;  increase  of, 
yy,  78,  166;  V.  m.  in  halluci- 
natory insanity,  170. 

Vomitus  matutinus,  257. 

"Vorbeireden,"  83,  227. 

"Wechselbalg,"  215. 

Weight,  bodily  w.  in  psychoses, 

96,  128. 
Whiskey,  117,  257. 
Will,  22-25;  morbid  activity  of, 

y^j;  treatment  of  m.  a.  of,  142. 
Wine,  73,  117,  257. 
Word-salad,  227. 
Worry,  a  cause  of  insanity,  113. 
Writing,  defective,  127. 

"Zornige  Manie,"  237. 
"Zwangsideen,"  68. 


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